The Provincial Spread and Scale of the Ontario eConsult Service: Evaluation of the First 2 Years

The Utilization of Electronic Consultations (eConsults) to Address Emerging Questions Related to Long COVID-19 in Ontario, Canada: Mixed Methods Analysis

Background

Long COVID is an often debilitating condition affecting millions of people. Its diverse clinical presentations make effective diagnosis and management at the primary care level difficult, while specialist services for long COVID face extensive wait times. An electronic consultation (eConsult) program in Ontario developed a long COVID specialist group to allow primary care providers (PCPs) prompt access to specialist advice for patients with long COVID.

Objective

This study aims to assess patterns of service use, response times, impact, and clinical content of eConsult cases submitted to an eConsult long COVID specialist group in Ontario.

Methods

This study is a mixed methods analysis of eConsults submitted by PCPs to the long COVID specialist group of 2 eConsult services (Champlain eConsult BASE and Ontario eConsult) between June 1, 2021, and July 31, 2022. Data sources included the use data collected automatically by the services, responses to a mandatory closeout survey, and the content of PCP questions and specialist responses (Champlain eConsult BASE service only). Clinical questions or responses were analyzed using 2 validated taxonomies. Descriptive statistics were used for survey responses and use data.

Results

A total of 40 PCPs submitted 47 eConsults through Champlain eConsult BASE and 197 PCPs submitted 228 cases through Ontario eConsult. The median specialist response time was 0.6 (IQR 0.19-2.36; mean 1.7, SD 2.29) days. The 5 most common symptoms of long COVID were fatigue (14/47, 30%), dyspnea (7/47, 15%), cough (6/47, 13%), altered sense of smell (ie, anosmia and parosmia; 6/47, 13%), and cognitive changes (6/47, 13%). The five main question categories asked by PCPs were: (1) management of chronic symptoms of COVID-19, (2) need for additional work-up or follow-up testing, (3) community resources to support or manage patients with long COVID, (4) diagnostic clarification, and (5) guidance regarding COVID-19 vaccination.

Conclusions

The long COVID groups provided rapid access to a multispecialty service that facilitated the avoidance of unnecessary face-to-face referrals. An assessment of eConsults highlighted 5 common question types, providing insight into potential gaps in knowledge among PCPs that could help guide medical education and policy.

Improving access to specialist care in correctional facilities through Ontario eConsult

OBJECTIVES

To evaluate the accessibility of multispecialty advice for primary care providers (PCPs) within correctional facilities, catering to the healthcare needs of individuals in federal custody in Ontario, Canada, through the utilization of electronic consultation (eConsult).

DESIGN

Retrospective, cross-sectional, descriptive analysis.

SETTING

eConsults submitted by PCPs within federal correctional facilities through the Ontario eConsult Service between April 1st, 2019, and March 31st, 2023.

PARTICIPANTS

906 completed eConsults were submitted by 21 PCPs in correctional facilities.

RESULTS

The top three specialties sent to were cardiology (46%, N = 417), dermatology (14%, N = 128), and endocrinology and metabolism (8%, N = 68). The median specialist response time was 0.9 days. The median time specialists spent responding to each case was 15 minutes. PCPs received advice on a new or additional course of action in 34% of eConsult cases. In-person specialist appointments were avoided in 81% of cases.

CONCLUSIONS

Ontario eConsult provides an ideal venue to improve access to multispecialty advice for people who are incarcerated. This service reduces the need for face-to-face specialist visits, decreases cost-of-care, and avoids unnecessary transportation outside of correctional facilities with potential security issues.

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.

Family Physician-to-Hospital Specialist Electronic Consultation and Access to Hospital Care: A Systematic Review

Importance

Globally, health care systems face challenges in managing health care costs while maintaining access to hospital care, quality of care, and a good work balance for caregivers. Electronic consultations (e-consultations)-defined as asynchronous, consultative communication between family physicians and hospital specialists-may offer advantages to face these challenges.

Objective

To provide a quantitative synthesis of the association of e-consultation with access to hospital care and the avoidance of hospital referrals.

Evidence Review

A systematic search through PubMed, MEDLINE, and Embase was conducted. Eligible studies included original research studies published from January 2010 to March 2023 in English, Dutch, or German that reported on outcomes associated with access to hospital care and the avoidance of hospital referrals. Reference lists of included articles were searched for additional studies. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) scores were assigned to assess quality of evidence.

Findings

The search strategy resulted in 583 records, of which 72 studies were eligible for data extraction after applying exclusion criteria. Most studies were observational, focused on multispecialty services, and were performed in either Canada or the US. Outcomes on access to hospital care and the avoidance of referrals indicated that e-consultation was associated with improved access to hospital care and an increase in avoided referrals to the hospital specialist, although outcomes greatly differed across studies. GRADE scores were low or very low across studies.

Conclusions and Relevance

In this systematic review of the association of e-consultation with access to hospital care and the avoidance of hospital referrals, results indicated that the use of e-consultation has greatly increased over the years. Although e-consultation was associated with improved access to hospital care and avoidance of hospital referrals, it was hard to draw a conclusion about these outcomes due to heterogeneity and lack of high-quality evidence (eg, from randomized clinical trials). Nevertheless, these results suggest that e-consultation seems to be a promising digital health care implementation, but more rigorous studies are needed; nonrandomized trial designs should be used, and appropriate outcomes should be chosen in future research on this topic.

Specialists accessing specialty advice: Evaluating utilization, benefits, and impact of care of an e-consultation service

INTRODUCTION

The usual referral pathway is from a primary care provider (PCP) to a specialist; however, specialists also refer to and consult with other specialists. Electronic consultation (eConsult) allows clinicians to submit questions on behalf of patients to specialists to receive timely advice. Most eConsult studies in the past have examined questions asked from PCPs to specialists. This study investigates the utilization of specialists submitting clinical questions to other specialists through the Ontario eConsult Service and identifies use-case scenarios where specialist-to-specialist eConsult may be beneficial.

METHODS

A retrospective, descriptive, cross-sectional analysis of eConsults submitted by specialists through the Ontario eConsult Service for 24 months (March 2019 to February 2021). Utilization data is collected automatically by the service, including specialty referred to, time billed, region, and results from a closeout survey which includes the referral outcome of the eConsult and the utility to the submitting clinician.

RESULTS

4% (n = 3285) of all eConsults sent within the study period were specialist-to-specialist, with the others being sent by a PCP. The number of specialist-to-specialist eConsults grew 120% following the onset of the COVID-19 pandemic. The top three specialties that submitted eConsults were pediatrics, internal medicine, and endocrinology. The top three specialties that specialists submitted to were dermatology, neurology, and hematology. A face-to-face referral was avoided in 69% of referrals.

CONCLUSION

Evaluating the utilization patterns of specialist-to-specialist eConsults allows us to better understand and expand the scope of eConsult services, which have traditionally been thought of as a workflow between a PCP and a specialist.

Supporting complex care in general practice via an eConsultant model of care: the Australian specialist perspective

BACKGROUND

Accessing timely specialist physician advice and guidance is of critical importance to both Australian GP specialists (GPs) and their patients. The traditional method of referral, triage and subsequent face-to-face (FTF) consultation is facing challenges from an ever increasing volume of referrals and the needs of underserved populations. In response to such issues, electronic consults (eConsults) have been successfully used internationally to provide GPs with a means of asynchronously accessing specialist physician advice and guidance within 72h. Few studies have addressed the potential impact of eConsults from the view of the non-GP specialist receiving the request, and none specifically related to specialist adult medicine physicians. The aim of this study was to determine the perceptions of current Royal Australasian College of Physicians (RACP) adult medicine Fellows towards establishing an eConsult model of care within their own clinical practice.

METHODS

Semi-structured interviews were conducted with 14 RACP adult medicine Fellows between December 2019 and February 2020. Purposive and snowball sampling strategies were used to recruit physicians of differing ages and gender from diverse specialties and healthcare settings. The data were subjected to a descriptive thematic analysis.

RESULTS

We describe five key themes of relevance to study participants: (1) improved access to non-GP specialist care; (2) the business model in relation to remuneration and time; (3) enhanced GP-Physician relationships; (4) impact on physician work-life balance; and (5) the need for a structured model of care. There was broad consensus that a significant number of outpatient referrals to adult medicine physicians would be more appropriately addressed in primary care with support via an asynchronous eConsult arrangement. RACP Fellows agreed this could improve access to timely specialist advice, place downward pressure on outpatient FTF clinic waiting times and reduce unnecessary patient travel.

CONCLUSION

These findings identify the drivers and barriers to the establishment of an Australian eConsultant model of care from the adult medicine physician's perspective.

An eConsultant versus a hospital-based outpatient consultation for general (internal) medicine: a costing analysis

BACKGROUND

The eConsultant model of care is an outpatient substitution approach which has been evaluated and implemented extensively internationally. It provides an asynchronous, digital, clinician-to-clinician advice service, giving primary care physicians remote access to specialist support for patient care within 3 business days. Results from initial trials of the eConsultant model in Australia support international evidence of reduced wait times and improved access to specialist input, avoidance of face-to-face hospital outpatient visits, and better integrated care. This study compared the cost of delivery of an eConsultant episode of care with that of a hospital-based outpatient appointment.

METHODS

A cost-minimisation analysis, using a decision analytic model, was used to compare the two approaches. eConsultant costs were calculated from specialist reported data (minutes spent preparing the response; the number of patients referred subsequently for a hospital-based outpatient appointment) and administration staff data (time spent recording the occasion-of-service). Outpatient costs were calculated using finance data and information from outpatient clinic managers at the hospital-based outpatient clinic. The primary outcome was incremental cost saving per patient from a hospital system perspective. Uncertainty was explored using one-way sensitivity analyses and characterised with probabilistic sensitivity analysis using 10,000 Monte Carlo simulations.

RESULTS

The traditional referral pathway cost estimate was $587.20/consult compared to $226.13/consult for an eConsultant episode: an efficiency saving of $361.07 per patient. The incremental difference between eConsultant and traditional care was most sensitive to the cost estimate of an outpatient attendance, the time for a specialist to complete an eConsult, and the probability of a patient requiring a face-to-face hospital-based attendance following an eConsult. However, at the upper bounds of each of these estimates, an eConsult remained the most cost-efficient model. In 96.5% of the Monte Carlo simulations eConsult was found to be more cost efficient than the traditional approach.

CONCLUSIONS

The eConsultant model of care was associated with a 61.5% efficiency gain, allowing diversion of support to hospital-based outpatient appointments.