Electronic Consultation System Research Articles

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.

Understanding Caregiver Perspectives on an Electronic Consultation and Referral System.

This study examined caregiver impressions of an electronic consultation and referral (ECR) system. Participants included 56 caregivers of primary care patients referred through the ECR system. Semistructured interviews and surveys were conducted between August 2018 and April 2019. Transcripts were coded and themes developed using thematic content analysis. A total of 51% of caregivers stated that they would prefer to see their child's primary care provider (PCP) for a specialty issue if they could receive the same quality of care. All caregivers who received an electronic consult (n = 28) said that they would utilize that process again. Three themes emerged: (1) caregivers expect immediate action prior to or instead of a specialty referral; (2) caregiver preferences for PCP versus specialist are mediated by both child and provider characteristics; (3) caregiver attitudes toward the ECR system are influenced by external considerations and experiences with the system. Results suggest caregivers value enhanced communication and immediate access to specialty input facilitated by the ECR system.

Anatomic pathology quality assurance: Developing an LIS based tracking and documentation module for intradepartmental consultations

BackgroundAn electronic intradepartmental consultation system for anatomic pathology (AP) was conceived and developed in the laboratory information system (LIS) in 2019. Previously, all surgical pathology intradepartmental consultative activities were initiated and documented with paper forms which circulated with the pertinent microscopic slides and were eventually filed. In this study, we discuss the implementation and utilization of an electronic intradepartmental AP consultation system. MethodsWorkflows and procedures were developed to organize intradepartmental surgical pathology consultations from the beginning to the end point of the consultative activities entirely using a paperless system that resided in the LIS. ResultsThe electronic consult system allowed electronic documentation of all steps of intradepartmental consultative activities. The system provided tracking ability for consulted cases and improved access to consult discussion for all departmental personnel, staff, and trainees. Consultation work queue was created for each pathologist and a summary of individual consultative workload was possible. Documentation of anatomic pathology quality assurance for intradepartmental consultative activity was easily assessed. ConclusionsThe electronic intradepartmental consult system has allowed our department to electronically track intradepartmental consult cases, store the consultative opinion text with the case, record the pathologists involved, and document the consultation for internal quality assurance review as well as for accrediting organizations. Summarization of pathologist workload related to consultative activity was quantifiable and optimization of the consultative process was maximized for education in an academic setting.

Managing high frequency users of an electronic consultation system in primary care: a quality improvement project

The COVID-19 pandemic prompted a rapid change in primary care provision. There was a significant shift from face-to-face appointments to remote methods such as electronic consultation (e-consultation). Patients from a...

Electronic Consultation Between Primary Care Providers and Radiologists.

OBJECTIVE. The purpose of this study was to assess the use of an electronic consultation platform to connect primary care providers and radiologists and provide opportunities for valuable consultation regarding diagnostic imaging in patients, as well as to identify opportunities for targeted education surrounding high-yield radiology topics. MATERIALS AND METHODS. A retrospective review was performed of consultations conducted using the electronic platform from September 2012 to January 2017. Consultations were classified by subspecialty (neuroradiology, thoracic, abdominal, musculoskeletal, or pediatric radiology), question type (workup, surveillance, education, specialist referral query, discharge, or other), anatomy, and pathology. Feedback surveys were completed by primary care providers after each consultation to evaluate timeliness, value, and impact on patient care. RESULTS. A total of 302 consultations were reviewed. Subspecialty breakdown was as follows: abdominal, 94/302 (31%); neuroradiology, 74/302 (25%); musculoskeletal, 61/302 (20%); thoracic, 56/302 (19%); and pediatric, 17/302 (6%). The majority of consultations pertained to patient workup (112/302 [37%]), surveillance of imaging findings (95/302 [31%]), and provider education (48/302 [16%]). Cystic lesions (38/302 [13%]), pain (24/302 [8%]), and bone lesions (21/302 [7%]) were the most queried conditions. Patient management was altered in 167 cases (55%), and unnecessary testing was avoided in 84 (28%). Providers rated the perceived value of the electronic consultation system as excellent in 227 cases (75%). CONCLUSION. The electronic consultation system allowed primary care providers to easily consult with radiologists, was perceived as high value by primary care providers, resulted in altered patient management, and avoided unnecessary imaging tests. We identified follow-up imaging of cystic lesions and imaging workup of pain in patients as opportunities for continuing medical education for primary care providers.

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.

Cancer care through the fire and flames: Three-year experience in utilizing of oncologic electronic consultation and referral system in the red zone of Thailand.

14 Background: “The South Thailand Insurgency” is burning violence in the deep south of Thailand. The insurgency which has been ongoing since 2004 has played out in the three southernmost districts of the country Pattani, Yala and Narathiwat and some area of Songkhla, so-called the “Red Zone”. The chronic terrorism had major affected on cancer service. Many cancer patients gave up on their lives due to struggle with the disease itself, financial constraints due to longstanding economic downturn and security concerns during travelling led to high loss to follow-up rate and treatment delay. We, an oncology service team working at Songklanagarind hospital, the only one cancer center served this area together with primary doctors and nurses in the Red Zone created a network and utilized an oncology-specific electronic consultation and referral system to make more efficient care. We reported its performance in 3 years period. Methods: Electronic consultation system (E-consult) was a web-based program developed to provide advice and facilitate the referral process in cancer care. Since October 2015, we prospectively surveyed the impact of this pilot project on the quality of service by counting waiting time, number of center visit until treatment, unnecessary referral avoidance, patient and potential cost saving compared to normal referral system. Results: E-consult reached out to 7 hospitals and 589 cancer patients successfully referred through E-consult. Among patients from the Red Zone, without E-consult, their average waiting time was 56.4 days, number of visit was 6.5 visits. The estimated financial burden was $758.8 per patient. After implementation of E-consult in 259 patients, average time to treatment was 41.5 days (p = 0.006) and a number of the counter visit was 2.3 visits (p < 0.001). Estimated financial burden could be reduced to $358.7(p < 0.001). Ultimately, we prevented 28 patients from unnecessary referral. Conclusions: In this special context the electronic referral system was helpful to improve medical access, timeliness to specialist care, saving the patients’ family time and resources. This model is widely applicable to oncology referral chain.

CN10 - Cancer care through the fire and flames: 3-year experience in the utilisation of electronic consultation and referral system at the red zone in Southern Thailand

Background“The South Thailand Insurgency” is burning violence in the deep south of Thailand. The insurgency which has been ongoing since 2004 has played out in the three southern most districts of the country Pattani, Yala and Narathiwat and some area of Songkhla, so-called the “Red Zone”. Violence such as daily ambush, bombing on soldiers and civilians, caused people living in terror. This violence has affected cancer service. Many cancer patients gave up on their lives due to struggle with the disease itself, security concerns, traveling and caregiving burden led to a high loss to follow-up rate. We, an oncology service team working at Songklanagarind hospital, the only one radiation and oncology center located in this area, in cooperation with doctors and nurses working in the Red Zone created a network and utilized an electronic consultation and referral system to alleviate these suffering. We preliminarily reported its real-life performance in 3 years period. MethodsElectronic consultation system(E-consult) was a web-based program designed and developed to provide advice and facilitate the referral process in cancer care. Since October 2015, we prospectively surveyed the impact of this pilot project on the quality of service by counting waiting time, the number of center visit until treatment, unnecessary referral avoidance, patient and potential cost saving compared to the normal referral system. ResultsE-consult reached out to 7 hospitals and 589 patient referred through E-consult. Among patients from the Red Zone, without E-consult, their average waiting time was 56.4 days, the number of visits was 6.5 visits. The estimated financial burden was $758.8 per patient. After the implementation of E-consult in 259 patients, the average time to treatment was 41.5 days (p=0.006) and the number of counter visit was 2.3 visits (p<0.001). The estimated financial burden was $358.7(p<0.001). We prevented 28 patients from the unnecessary referral. ConclusionsIn this special context, the electronic referral system not only was helpful to improve medical access, timeliness to specialist care, saving the patients’ family time and resources but it also supports the doctors and nurses on duty in the Red Zone. Legal entity responsible for the studyNanthiya Rattanakhot. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Digital and online symptom checkers and assessment services for urgent care to inform a new digital platform: a systematic review

Background Digital and online symptom checkers and assessment services are used by patients seeking guidance about health problems. NHS England is planning to introduce a digital platform (NHS111 Online) to operate alongside the NHS111 urgent-care telephone service. This review focuses on digital and online symptom checkers for urgent health problems. Objectives This systematic review was commissioned to provide NHS England with an independent review of previous research in this area to inform strategic decision-making and service design. Data sources Focused searches of seven bibliographic databases were performed and supplemented by phrase searching for names of symptom checker systems and citation searches of key included studies. The bibliographic databases searched were MEDLINE, EMBASE, The Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature), HMIC (Health Management Information Consortium), Web of Science and the Association of Computing Machinery (ACM) Digital Library, from inception up to April 2018. Review methods Brief inclusion criteria were (1) population – general population seeking information online or digitally to address an urgent health problem; (2) intervention – any online or digital service designed to assess symptoms, provide health advice and direct patients to appropriate services; and (3) comparator – telephone or face-to-face assessment, comparative performance in tests or simulations (studies with no comparator were included if they reported relevant outcomes). Outcomes of interest included safety, clinical effectiveness, costs or cost-effectiveness, diagnostic and triage accuracy, use of and contacts with health services, compliance with advice received, patient/carer satisfaction, and equity and inclusion. Inclusion was not restricted by study design. Screening studies for inclusion, data extraction and quality assessment were carried out by one reviewer with a sample checked for accuracy and consistency. Final decisions on study inclusion were taken by consensus of the review team. A narrative synthesis of the included studies was performed and structured around the predefined research questions and key outcomes. The overall strength of evidence for each outcome was classified as ‘stronger’, ‘weaker’, ‘conflicting’ or ‘insufficient’, based on study numbers and design. Results In total, 29 publications describing 27 studies were included. Studies were diverse in their design and methodology. The overall strength of the evidence was weak because it was largely based on observational studies and with a substantial component of non-peer-reviewed grey literature. There was little evidence to suggest that symptom checkers are unsafe, but studies evaluating their safety were generally short term and small scale. Diagnostic accuracy was highly variable between different systems but was generally low. Algorithm-based triage tended to be more risk averse than that of health professionals. Inconsistent evidence was found on effects on service use. There was very limited evidence on patients’ reactions to online triage advice. The studies showed that younger and more highly educated people are more likely to use these services. Study participants generally expressed high levels of satisfaction with digital and online triage services, albeit in uncontrolled studies. Limitations Findings from symptom checker systems for specific conditions may not be applicable to more general systems and vice versa. Studies of symptom checkers as part of electronic consultation systems in general practice were also included, which is a slightly different setting from a general ‘digital 111’ service. Most studies were screened by one reviewer. Conclusions Major uncertainties surround the probable impact of digital 111 services on most outcomes. It will be important to monitor and evaluate the services using all available data sources and by commissioning high-quality research. Future work Priorities for research include comparisons of different systems, rigorous economic evaluations and investigations of patient pathways. Study registration The study is registered as PROSPERO CRD42018093564. Funding The National Institute for Health Research Health Services and Delivery Research programme.

SUN-234 Electronic consultations (eConsult) to enhance access to nephrologists care: what are the barriers and facilitators to implementation?

The 2017 Global Burden of Disease Study reported that less than half of all countries had enough health-care workers required to deliver quality healthcare (30 physicians, 100 nurses or midwives, and five pharmacists per 10,000 people). Moreover, the recent Global Kidney Health Atlas (GKHA) project reported for the first time a global nephrologists density of 8.83 per million populations with significant disparities between countries. Against this drawback of shortages in all healthcare providers in general and in nephrologists in particular, health Information technologies (HIT) are promising tools to facilitate kidney care especially access to nephrologist care where it is lacking. Electronic consultation (e-Consult) systems are an example of an asynchronous HIT that allows communication between providers at a distance and showed evidence for increased access to specialist care and a decrease in inappropriate referrals. Despite this reported benefits, eConsult implementations remain limited to few jurisdictions. In this study, we sought to review the reported experience of eConsult implementation in the literature focusing on factors that favour or hinder implementation. The choice for a scoping review methodology was informed by the complex nature of the intervention (eConsult) and expected heterogeneity of the literature. We leveraged the Arksey & O’Malley’s framework on conducting scoping reviews which involved five steps 1) identifying the research question; 2) identifying the relevant studies; 3) study selection; 4) charting the data; and 5) reporting the results, and an optional step of a consultation exercise with relevant stakeholders. We searched key electronic databases (Medline, Embase, Wiley Cochrane Library, CINAHL, Cochrane Library, and PsycINFO). No restriction on study design, date or language. We analyzed the data thematically and presented it using the Quadruple aim framework. This framework has four components of the patient, provider (primary care providers, specialists), population health and cost that need to be pursued simultaneously in order to improve health care. After screening 2579 titles and abstracts, 83 unique documents fulfilled our eligibility criteria. Majority of identified studies were published in the last ten years and were from seven countries (Finland, Ireland, Canada, Spain, Brazil, United Kingdom, Netherlands and United States of America). We mapped the literature on eConsult barriers and facilitators using the Quadruple Aim framework. We identified several key barriers and facilitators to eConsult implementation at patient-, provider-, and health care system-levels and cost-related factors. All of the identified literature were from few high-income countries with no reported experiences from low- and middle-income countries identified. The presence of numerous modifiable providers and cost-related barriers are potential targets for tailored interventions to increase adoption and implementation of eConsult. Future studies should try to elucidate the prevalence of identified barriers among providers through mixed methods studies. Our findings are relevant to inform the development and implementation of eConsult systems as platforms to enhance access to specialists care particularly for countries with limited access to nephrologists care.

706-P: Enrollment in a Diabetes Prevention Program in the San Francisco Safety Net

There is a crucial need for successful strategies for DPP enrollment and implementation in safety net populations which are disproportionally affected by diabetes. We examine enrollment outcomes in a DPP referral program in the San Francisco Health Network, a safety net serving over 140,000 patients. Overweight patients with prediabetes are referred via an electronic consultation system from 20 community primary care and weight management clinics. Eligible Spanish- or English-speaking patients are contacted by a patient navigator, screened for eligibility, given a readiness assessment and if appropriate, invited to participate in either a digital or in-person DPP. Patients interested in an in-person program but not ready for the full DPP are offered the 6-week Diabetes Empowerment Education Program (DEEP). From August 2017 to November 2018, 305 patient referrals were evaluated: 44 (14.4%) did not qualify after chart review (e.g., they already had diabetes, were not prediabetic, or were out of network), 124 (40.7%) were unable to be reached (13 did not have a working phone, 23 had no voicemail, 88 did not return calls) and 137 (44.9%) patients were reached. Of those 137, 26 (19.0%) were unaware that their provider had referred them or were not interested while 111 (81.0%) were interested. Ten of those patients were not ready for the full DPP and chose DEEP. The remaining 101 patients completed the intake process, passed a readiness assessment and chose to enroll in a DPP: 25 (24.8%) chose a digital DPP and 76 (75.2%) an in-person DPP with a nonsignificant trend towards a preference for a digital DPP by younger patients. Thus, of 305 initial referrals less than half (36.4%) were successfully enrolled. The primary challenge was difficulty reaching and engaging patients. Potential strategies to improve patient yield include better education of referring providers on initial readiness assessments, DPP eligibility, and the importance of a good contact number. Measuring weight loss outcomes in these patients will be crucial. Disclosure S. Kim: None. A.H. Tang: None. C. Kuo: None. R.S. Garcia: None. S. Kim: None. E. Murphy: None.

Spectrum of rhabdomyolysis in an acute hospital

Rhabdomyolysis is a state of muscle necrosis with the hallmark being elevated creatine kinase that may cause acute kidney injury with serious consequences. It happens in many clinical settings. We sought to investigate all cases of rhabdomyolysis admitted to an acute hospital in Ireland over one calendar year. All cases of rhabdomyolysis admitted to a tertiary hospital over a 12-month period were reviewed. It was defined as serum creatine kinase greater than five times upper limit normal. The incidence, presenting characteristics and clinical outcomes, was collected from electronic records, electronic consult system and discharge summaries. Rhabdomyolysis was observed in 306 (1.7%) of all 18,297 admissions. It was seen most commonly in the setting of acute coronary syndrome (19.6%), post-operative state (18.0%), long-term confinement in the same position (16.3%), infection (9.2%) and seizures (6.5%). Overall mortality in this group was 16%. Acute kidney injury occurred in 43% of patients. Those with severe acute kidney injury (stage 3) had a mortality of 50%. Length of stay was significantly prolonged in the presence of acute kidney injury (p < 0.001). Surprisingly, in 44% of those with acute kidney injury, nephrology advice was not requested. Rhabdomyolysis is a common and a serious clinical condition across many specialties in an acute hospital that would likely benefit from nephrology involvement should acute kidney injury supervene.

Electronic Advice Request System for Nephrology in Alberta: Pilot Results and Implementation.

Background:Residents of rural areas of Alberta face significant barriers regarding access to specialist care, resulting in delays in provision of optimal care. Electronic referral and consultation systems are promising tools for facilitating timely access to specialist care, especially for people living in rural locations.Objective:To report our initial experience with the launch of an electronic advice request system for ambulatory kidney care in Alberta, Canada.Methods:We analyzed electronic advice requests for nephrology services in Alberta after the system’s pilot launch, from October 2016 to December 2017. Data for province-wide advice request utility by primary care providers (PCPs) were extracted from Alberta Netcare for analysis.Results:The total number of electronic advice requests directed to nephrology was 118 (mean number of requests: 2 per week). Only 31 (26.3%) of the cases required a face-to-face clinic visit with a nephrologist. Most (87; 73.7%) cases were managed by PCPs with ongoing nephrologist support via the advice request tool. Typical nephrologist response time was 5.7 ± 0.6 (mean ± SEM) days.Conclusion:These preliminary data suggest that the electronic advice request program has potential to enhance timely access to specialist kidney care and minimize unnecessary nephrologist visits while reducing response time. Broad implementation of this system may have a substantial positive impact on health outcomes and improve cost-effectiveness for nephrology care in the long term, particularly in rural communities of Alberta.

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

Offering eConsult to Family Physicians With Patients on a Pain Clinic Wait List: An Outreach Exercise.

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

Shared Care: Using an Electronic Consult Form to Facilitate Primary Care Provider–Specialty Care Coordination

ObjectiveThe quality of children's health is compromised by poor care coordination between primary care providers (PCPs) and specialists. Our objective was to determine how an electronic consultation and referral system impacts referral patterns and PCP–specialist communication. MethodsThe primary care clinic at Boston Children's Hospital piloted an electronic referral and consultation system with the neurology and gastroenterology departments from April 1, 2014, to October 31, 2016. PCPs completed an electronic consult form, and if needed, specialists replied with advice or facilitated expedited appointments. Specialist response times, referral rates, wait times, and completion rates for specialty visits were tracked. PCPs and specialists also completed a survey to evaluate feasibility and satisfaction. ResultsA total of 82 PCPs placed 510 consults during the pilot period. Specialists responded to 88% of requests within 3 business days. Eighteen percent of specialty visits were deferred and 21% were expedited. Wait times for specialty appointments to both departments significantly decreased, from 48 to 34 days (P < .001), and completion rates improved from 58% to 70% (P < .01), but referral volumes remained stable (25 per month to 23 per month; P = .29). Most PCPs said the Shared Care system facilitated better communication with specialists (89%) and enabled them to provide superior patient care (92%). Specialists reported that the system required a minimal amount of time and enabled them to educate PCPs and triage referrals. ConclusionsImplementation of an electronic referral and consultation system was feasible and provided timely access to specialty care, but did not affect referral volume. This system could serve as a model for other health care organizations and specialties.

Use of an electronic consultation system in primary care: a qualitative interview study.

BackgroundThe level of demand on primary care continues to increase. Electronic or e-consultations enable patients to consult their GP online and have been promoted as having potential to improve access and efficiency.AimTo evaluate whether an e-consultation system improves the ability of practice staff to manage workload and access.Design and settingA qualitative interview study in general practices in the West of England that piloted an e-consultation system for 15 months during 2015 and 2016.MethodPractices were purposefully sampled by location and level of e-consultation use. Clinical, administrative, and management staff were recruited at each practice. Interviews were transcribed and analysed thematically.ResultsTwenty-three interviews were carried out across six general practices. Routine e-consultations offered benefits for the practice because they could be completed without direct contact between GP and patient. However, most e-consultations resulted in GPs needing to follow up with a telephone or face-to-face appointment because the e-consultation did not contain sufficient information to inform clinical decision making. This was perceived as adding to the workload and providing some patients with an alternative route into the appointment system. Although this was seen as offering some patient benefit, there appeared to be fewer benefits for the practices.ConclusionThe experiences of the practices in this study demonstrate that the technology, in its current form, fell short of providing an effective platform for clinicians to consult with patients and did not justify their financial investment in the system. The study also highlights the challenges of remote consultations, which lack the facility for real time interactions.

Use of Electronic Consultation System to Improve Access to Care in Pediatric Hematology/Oncology.

Electronic consultations (eConsult) allow for communication between primary care providers and specialists in an asynchronous manner. This study examined provider satisfaction, topics of interest, and efficiency of eConsult in pediatric hematology/oncology in Ottawa, Canada. We conducted a cross-sectional assessment of all eConsult cases directed to pediatric hematology/oncology specialists using the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service from June 1, 2014 to May 31, 2016. There were 1064 eConsults to pediatrics during the study timeperiod and pediatric hematology/oncology consults accounted for 8% (85). During the same study timeperiod, 524 consults were seen in the pediatric hematology/oncology clinic. The majority of the eConsults were for hematology (90.5%) in contrast to oncology topics (9.5%). The most common topics were anemia, hemoglobinopathy, bleeding disorder, and thrombotic state. Primary care providers rated the eConsult service very highly, and their comments were very positive. The eConsult service resulted in deferral of 40% of consults originally contemplated to require a face-to-face specialist visit. This study showed successful implementation and use of the eConsult service for pediatric hematology/oncology and resulted in avoidance of a large number of face-to-face consultation. The common topics identified areas for continuing medical education.

Understanding the Potential for Patient Engagement in Electronic Consultation and Referral Systems: Lessons From One Safety Net System.

To understand patient, primary care clinician (PCC), and subspecialist perspectives on potential, unexplored roles for patients in electronic consultation and referral (eCR) systems. Primary 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. This 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). Focus groups were audio-recorded and transcribed. Two researchers coded the transcripts to identify recurrent themes. Survey data were analyzed using summary and bivariate statistics. Patients 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. Results suggest a continuum of opportunities for patients and their caregivers to engage in eCR systems.

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.