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With the rising demand for clinical genetics services, it is a challenge for clinical geneticists to meet the needs of patients and referring primary care providers in a timely way, using current models of genetics health care delivery. One method of providing primary care providers with greater access to clinical genetics expertise is through an electronic consultation (eConsult) service. We describe here a pilot project of a clinical genetics eConsult service that our genetics centre in Eastern Ontario, Canada provided, using the Champlain Building Access to Specialists through eConsultation (BASE)TM web-based application. We analyzed 111 genetics eConsults submitted by primary care providers to a single clinical geneticist over a 28-month time period. More than half (54%) of the eConsult questions were regarding (1) hereditary cancer and (2) genetic syndromes, with the remainder encompassing a wide variety of clinical genetics topics. We avoided a referral to the Genetics clinic for an in-person appointment for 30% of the eConsult cases, based on a contemplated referral rate to Genetics clinic of 72% prior to eConsult and a planned referral rate to Genetics clinic of 42% following all eConsults. Primary care providers rated the eConsult service of high value to themselves and also to their patients. This pilot service supports the potential of an eConsultation service to create a stronger and more dynamic link between clinical genetics and primary care providers, which may lead to better patient care.

Cancer poses a significant global health burden. With advances in screening and treatment, there are now a growing number of cancer survivors with complex needs, requiring the involvement of multiple health care providers. Previous studies have identified problems related to communication and care coordination between primary care providers (PCPs) and cancer specialists. This study aimed to examine whether a web- and text-based asynchronous system (eOncoNote) could facilitate communication between PCPs and cancer specialists (oncologists and oncology nurses) to improve patient-reported continuity of care among patients receiving treatment or posttreatment survivorship care. In this pragmatic randomized controlled trial, a total of 173 patients were randomly assigned to either the intervention group (eOncoNote plus usual methods of communication between PCPs and cancer specialists) or a control group (usual communication only), including 104 (60.1%) patients in the survivorship phase (breast and colorectal cancer) and 69 (39.9%) patients in the treatment phase (breast and prostate cancer). The primary outcome was patient-reported team and cross-boundary continuity (Nijmegen Continuity Questionnaire). Secondary outcome measures included the Generalized Anxiety Disorder Screener (GAD-7), Patient Health Questionnaire on Major Depression, and Picker Patient Experience Questionnaire. Patients completed the questionnaires at baseline and at 2 points following randomization. Patients in the treatment phase completed follow-up questionnaires at 1 month and at either 4 months (patients with prostate cancer) or 6 months following randomization (patients with breast cancer). Patients in the survivorship phase completed follow-up questionnaires at 6 months and at 12 months following randomization. The results did not show an intervention effect on the primary outcome of team and cross-boundary continuity of care or on the secondary outcomes of depression and patient experience with their health care. However, there was an intervention effect on anxiety. In the treatment phase, there was a statistically significant difference in the change score from baseline to the 1-month follow-up for GAD-7 (mean difference -2.3; P=.03). In the survivorship phase, there was a statistically significant difference in the change score for GAD-7 between baseline and the 6-month follow-up (mean difference -1.7; P=.03) and between baseline and the 12-month follow-up (mean difference -2.4; P=.004). PCPs' and cancer specialists' access to eOncoNote is not significantly associated with patient-reported continuity of care. However, PCPs' and cancer specialists' access to the eOncoNote intervention may be a factor in reducing patient anxiety. ClinicalTrials.gov NCT03333785; https://clinicaltrials.gov/ct2/show/NCT03333785.

Background: The Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service allows primary care providers (PCPs) to submit patient-specific clinical questions to specialists via a secure web service. Objective: Our objective was to describe the types of nephrology questions asked through an eConsult service based in eastern Ontario and assess the service’s impact on the need for face-to-face consultations. Design: Cross-sectional study using descriptive statistics was conducted using nephrology cases submitted between May 2011 and January 2015. Specialist response times and referral avoidance were collected. Validated taxonomies were used to categorize cases based on question type and content. Setting: Patient cases were collected from PCPs in Ottawa, Ontario, and its surrounding communities and submitted to nephrologists at the Ottawa Hospital. Patients: During the study period, 155 eConsults were submitted to nephrology. Measurement: Utilization and survey data were collected for all eConsults. Questions were categorized by subject matter and question type. Results: A traditional consult visit was avoided in 45% of cases based on the specialist’s advice; 21% cases required referral. Thirty-two percent of eConsults took specialists less than 10 minutes to complete, 55% took 10 to 15 minutes, 11% took 15 to 20 minutes, and only 2% took more than 20 minutes. Twenty-five percent of cases were related to proteinuria, 18% to chronic kidney disease (CKD), 17% to imaging, and 12% to drug use in CKD. Common question types included general management (37%), interpretation of laboratory test (17%), interpretation of an image report (13%), and need for nephrology referral (11%). Limitations: Some consults contained multiple categories and question types. Our analyses required a single classification, which may underestimate the number of questions in each category. Our study had a small sample size using cases completed in a single health jurisdiction, limiting generalizability. Conclusions: The Champlain BASE™ eConsult service provided guidance to PCPs and reduced the number of face-to-face nephrology consultations.

Champlain BASE™ (Building Access to Specialists through eConsultation) is a web-based asynchronous electronic communication service that allows primary-care- practitioners (PCPs) to submit \"elective\" clinical questions to a specialist. For adults, PCPs have reported improved access and timeliness to specialist advice, averted face-to-face specialist referrals in up to 40% of cases and high provider satisfaction. To determine whether the expansion of eConsult to a pediatric setting would result in similar measures of improved healthcare system process and high provider acceptance reported in adults. Prospective observational cohort study. Single Canadian tertiary-care academic pediatric hospital (June 2014-16) servicing 1.2 million people. 1. PCPs already using eConsult. 2.Volunteer pediatric specialists provided services in addition to their regular workload. 3.Pediatric patients (< 18 years-old) referred for none-acute care conditions. Specialty service utilization and access, impact on PCP course-of-action and referral-patterns and survey-based provider satisfaction data were collected. 1064 eConsult requests from 367 PCPs were answered by 23 pediatric specialists representing 14 specialty-services. The top three specialties represented were: General Pediatrics 393 cases (36.9%), Orthopedics 162 (15.2%) and Psychiatry 123 (11.6%). Median specialist response time was 0.9 days (range <1 hour-27 days), most consults (63.2%) required <10minutes to complete and 21/21(100%) specialist survey-respondents reported minimal workload burden. For 515/1064(48.4%) referrals, PCPs received advice for a new or additional course of action; 391/1064(36.7%) referrals resulted in an averted face-to-face specialist visit. In 9 specialties with complete data, the median wait-time was significantly less (p<0.001) for an eConsult (1 day, 95%CI:0.9-1.2) compared with a face-to-face referral (132 days; 95%CI:127-136). The majority (>93.3%) of PCPs rated eConsult as very good/excellent value for both patients and themselves. All specialist survey-respondents indicated eConsult should be a continued service. Similar to adults, eConsult improves PCP access and timeliness to elective pediatric specialist advice and influences their care decisions, while reporting high end-user satisfaction. Further study is warranted to assess impact on resource utilization and clinical outcomes.

Background: Residents of remote communities face inequities in access to specialists, excessive wait times, and poorly coordinated care. The Champlain BASE TM (Building Access to Specialists through eConsultation) service facilitates asynchronous communication between primary care providers (PCP) and specialists. The service was extended to several PCPs in Nunavut in 2014. Objective: To (1) describe the use of eConsult services in Nunavut, and (2) conduct a costing evaluation. Design: A cross-sectional study and cost analysis of all eConsult cases submitted between August 2014 and April 2016. Results: PCPs from Nunavut submitted 165 eConsult cases. The most popular specialties were dermatology (16%), cardiology (8%), endocrinology (7%), otolaryngology (7%), and obstetrics/gynaecology (7%). Specialists provided a response in a median of 0.9 days (IQR=0.3-3.0, range=0.01-15.02). In 35% of cases, PCPs were able to avoid the face-to-face specialist visits they had originally planned for their patients. Total savings associated with eConsult in Nunavut are estimated at $180,552.73 or $1,100.93 per eConsult. Conclusions: The eConsult service provided patients in Nunavut's remote communities with prompt access to specialist advice. The service's chief advantage in Canada's northern communities is its ability to offer electronic access to a breadth of specialties far greater than could be supported locally. Our findings suggest that a territory-wide adoption of eConsult would generate enormous savings.

The Ontario electronic consultation (eConsult) service allows a primary care provider (PCP) to access specialist advice through 2 models: the direct-to-specialist (DTS) model, where PCPs select a specialist from a directory, and the Building Access to Specialists Through eConsultation (BASE)-managed specialty service, where PCPs choose a specialty group and are assigned a specialist from a qualified pool based on availability. The aim of this study is to examine patterns of use between the 2 models of eConsult delivery. We conducted a cross-sectional analysis of utilization data collected from eConsults completed between October 2018 and September 2019. Cases were grouped based on the model used for submission (ie, BASE or DTS). Each model was assessed for the number of cases over time, specialty distribution, proportion resulting in new or additional information, impact on PCPs' decisions to refer, and billing time. PCPs submitted 26,121 eConsults during the study period. The monthly case volume increased by 43% over the duration of the study, primarily in the BASE model (66% compared to 6% for DTS). PCPs were able to confirm a course of action that they originally had in mind in 41.4% (6373/15,376) of BASE cases and 41.3% (3363/8136) of DTS cases and received advice for a new or additional course of action in 54.7% (8418/15,376) of BASE cases and 56.3% (4582/8136) of DTS cases. A referral was originally contemplated but avoided in 51.3% (7887/15,376) of BASE cases and 53.3% (4336/8136) of DTS cases, originally contemplated and still needed in 19.4% (2986/15,376) of BASE cases and 17.7% (1438/8136) of DTS cases, and neither originally contemplated nor needed in 21.7% (3334/15,376) of BASE cases and 21.9% (1781/8136) of DTS cases. Both eConsult models had strong uptake. Use patterns varied between models, with the majority of growth occurring under BASE, but survey responses showed that both models provided similar outcomes in terms of new information offered and impact on decision to refer.

To assess the effect of eConsultation in providing Orthopaedic Surgery specialist service to patients in Nunavut. A cross-sectional study of 161 Orthopaedic Surgery consultations received from primary care providers (PCPs) in Nunavut via the Champlain Building Access to Specialist service through eConsult (BASE TM ) service over the 2-year period from January 2017 to December 2018. Data captured were: reason for consultation, impact of advice on referral, perceived value to the PCPs and time spent. eConsult avoided unnecessary in-person consultation 62% of the time while catching 5% of the referrals that would have otherwise been missed. PCP referral behaviour was modified 48% of the time. 94% of eConsults were rated as valuable to PCPs in their practice and 100% of eConsults resulted in actionable advice. Further, eConsults took an average of 15.4 minutes of specialist time to complete, and the mean time from referral to response was 1.4 days. eConsultation spares unnecessary consultation to Orthopaedic Surgery, catches important referrals that would have otherwise been missed, decreases wait time, and may reduce cost in remote healthcare systems such as Nunavut.

Background Electronic consultation (eConsult) services are secure online applications facilitating provider-to-provider communication. They have been found to improve access to specialist care. However, little is known about eConsult’s impact on family physicians’ referral rates to specialty care. The objective of this study was to assess the impact of a multispecialty eConsult service on referral rates from primary care. Methods In this parallel-arm, randomized controlled trial, we recruited primary care providers across Ontario not previously enrolled with eConsult. We randomly assigned participants to intervention and control arms. Participants in the intervention arm received access to eConsult for a period of 1 year while those in the control arm received no access to eConsult. The main outcome was specialist referral rate, expressed as the total number of referrals to (1) specialties available through eConsult, and (2) all medical specialties, per 100 patients seen. Multivariable negative binomial regression analysis was used to evaluate the effect of the intervention before and after adjusting for provider characteristics, using health administrative data. Results One hundred and thirteen participants were randomized (56 to control and 57 to intervention). For the primary outcome (referrals to eConsult specialties), the results show a statistically significant reduction in the number of referrals in both arms (control-arm Rate Ratio (RR), 0.85, 95% CI 0.79 to 0.91; intervention-arm RR, 0.80, 95% CI 0.74 to 0.85; unadjusted and adjusted RR values almost identical), as compared to the baseline data collected during the 12-month period before randomization, with a non-statistically significant 6% greater reduction in referrals in the intervention arm, compared to the control arm (unadjusted RR 0.94, 95% CI 0.85 to 1.03; adjusted RR 0.93, 95% CI 0.85 to 1.03). Conclusions Our randomized controlled trial of a multispecialty eConsult service demonstrated inconclusive results in terms of the impact of eConsult on physician referral rates. Findings are discussed in light of important limitations associated with conducting randomized controlled trials (RCTs) of complex interventions in the primary care context with intent to inform the design and analysis of future trials. Trial registration Clinicaltrials.gov, ID: NCT02053467 . Registered prospectively on 3 February 2014.

Background Frailty is a complex age-related clinical condition that increases vulnerability to stressors. Early recognition of frailty is challenging. While primary care providers (PCPs) serve as the first point of contact for most older adults, convenient tools for identifying frailty in primary care are lacking. Electronic consultation (eConsult), a platform connecting PCPs to specialists, is a rich source of provider-to-provider communication data. Text-based patient descriptions on eConsult may provide opportunities for earlier identification of frailty. We sought to explore the feasibility and validity of identifying frailty status using eConsult data. Methods eConsult cases closed in 2019 and submitted on behalf of long-term care (LTC) residents or community-dwelling older adults were sampled. A list of frailty-related terms was compiled through a review of the literature and consultation with experts. To identify frailty, eConsult text was parsed to measure the frequency of frailty-related terms. Feasibility of this approach was assessed by examining the availability of frailty-related terms in eConsult communication logs, and by asking clinicians to indicate whether they can assess likelihood of frailty by reviewing the cases. Construct validity was assessed by comparing the number of frailty-related terms in cases about LTC residents with those about community-dwelling older adults. Criterion validity was assessed by comparing clinicians' ratings of frailty to the frequency of frailty-related terms. Results One hundred thirteen LTC and 112 community cases were included. Frailty-related terms identified per case averaged 4.55 ± 3.95 in LTC and 1.96 ± 2.68 in the community ( p  < .001). Clinicians consistently rated cases with ≥ 5 frailty-related terms as highly likely of living with frailty. Conclusions The availability of frailty-related terms establishes the feasibility of using provider-to-provider communication on eConsult to identify patients with high likelihood of living with this condition. The higher average of frailty-related terms in LTC (versus community) cases, and agreement between clinician-provided frailty ratings and the frequency of frailty-related terms, support the validity of an eConsult-based approach to identifying frailty. There is potential for eConsult to be used as a case-finding tool in primary care for early recognition and proactive initiation of care processes for older patients living with frailty.

Our study evaluates the impact of feedback sent to specialists participating in eConsult services. eConsult Specialists from two eConsult services in Ontario, Canada, received feedback on their use of eConsult via bi-annual specialist reports. An 11-item survey was developed to evaluate the impact, content, and distribution process of these specialist reports. We distributed 742 specialist reports in March 2021 and surveyed the specialists in July 2021. Our findings show that specialists largely felt that the feedback received validated their efforts (83%) and that receiving the report made them more likely to continue to participate in the eConsult service (59%). Most did not feel judged (74%) or distressed (79%) by the reports, and 72% said that reporting the median self-reported billing time did not impact their own billing times. Overall, eConsult services can capture, report and aggregate data valuable to specialists and is useful for Continuing Professional Development. Benefits and lack of risk implementing this type of feedback should encourage other services to consider similar processes.