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Objective: The coronavirus disease 2019 (COVID-19) pandemic forced many clinicians to rapidly adopt changes in their practice. In this study, we compared patterns of utilization of Ontario eConsult before and after the onset of the COVID-19 pandemic, to assess COVID 19's impact on how eConsult is used. Materials and Methods: We conducted a longitudinal analysis of registration and utilization data for Ontario eConsult. All primary care providers (PCPs) and specialists who joined the service between March 2019 and November 2020, and all eConsult cases closed during the same period were included. The data were divided into two timeframes for comparison: prepandemic (March 2019-February 2020) and pandemic (March 2020-November 2020). Results: In total, 5,925 PCPs joined during the study period, more than doubling total enrollment to 11,397. The average monthly number of eConsults increased from 2,405 (standard deviation [SD] = 260) prepandemic to 3,906 (SD = 420) pandemic. Case volume jumped to 24.3% in the first month of the pandemic, and increased by 71% during the COVID-19 pandemic timeframe. The median response time was similar in both timeframes (prepandemic: 1.0 days; pandemic: 0.9 days). The proportion of cases resulting in new/additional information (prepandemic: 55%, pandemic: 57%) or avoidance of a contemplated referral (prepandemic: 52%, pandemic: 51%) remained consistent between timeframes. Conclusions: Registration to and usage of eConsult increased during the pandemic. Metrics of the service's impact, including response time, percentage of cases resulting in new or additional information, and avoidance of originally contemplated referrals were all consistent between the prepandemic and COVID-19 pandemic timeframes, suggesting scalability.

Background Access to transgender care in Canada is poor. Although primary care providers are ideally positioned to initiate care, many feel uncomfortable providing transgender care. This study aimed to explore the impact of an electronic consultation (eConsult) service between primary care providers and transgender care specialists on access to care and to explore the content of clinical questions that were asked. Methods This was a retrospective mixed methods analysis of 62 eConsults submitted between January 2017 and December 2018 by primary care providers to specialists in transgender care in a health region in eastern Ontario, Canada. A descriptive analysis was conducted to assess the average response time and the total time spent by the specialist for the eConsults. An inductive and deductive content analysis was carried out to identify common themes of clinical questions being asked to transgender specialists. A post-eConsult survey completed by primary care providers was assessed to gain insight into avoided face-to-face referrals and overall provider satisfaction. Results The median specialist response time was 1.2 days (range: 1 h to 5 days) and the average time spent by specialists per eConsult was 18 min (range: 10 to 40 min). The qualitative analysis identified six major themes: 1) interpretation/management of abnormal bloodwork, 2) change in management due to lack of desired effect/hormone levels not a target, 3) initiation of hormone therapy/initial work up, 4) management of adverse effects of hormone therapy, 5) transition related surgery counseling and post-op complications, and 6) management of patients with comorbidities. Approximately one-third of eConsults resulted in an avoided face-to-face referral and 95% of primary care providers rated the value of their eConsult as a 5 (excellent value) or 4. Conclusions This study demonstrated that a transgender eConsult service has potential to significantly improve access to care for transgender patients. Given the importance that timely access has on improving mental health and reducing suicide attempts, eConsult has the potential to make a substantial clinical impact on this population. Identified themes of eConsult questions provides insight into potential gaps in knowledge amongst primary care providers that could help inform future continuing education events.

Objectives To evaluate the acceptability of the Integrated Parkinson’s disease Care Network (IPCN) from the perspectives of persons with Parkinson’s disease (PD), their care partners and healthcare providers, including identification of important components and areas for improvement. Methods We used a descriptive qualitative approach with interviews (n = 15) and focus groups (n = 31) with persons with PD who were newly diagnosed and those with advanced PD, care partners and healthcare providers. Questions were designed to gather feedback on each component of the IPCN. Results Four overarching categories emerged: CCI support, New knowledge, Goal identification and achievement, and Readiness for self-management. These represent important aspects of participants’ experiences of the IPCN. Conclusion Most participants experienced the IPCN as helpful for managing living with PD and accessing resources. The relationship with the CCI was a critical component; the CCI was perceived to be knowledgeable, accessible, and responsive. Practice implications The IPCN is a model to promote coordinated care and self-management. This study supports the key components of the IPCN as important for supporting patients in managing their lives with PD. Incorporation of other strategies to support self-management may enhance the model. Availability of and access to community resources was identified as an ongoing challenge.

Background In Canada, wait times for access to specialized rheumatology services have increased, leading to new strategies to improve timely care; electronic consultations (eConsults) enable providers to ask specialists a clinical question using a secure platform, often reducing the need for a face-to-face visit. In this study, we sought to compare the types of referrals received through fax versus eConsult and to determine whether faxed referrals could be addressed using eConsult. Methods We conducted a descriptive study of consecutive faxed referrals sent to a tertiary care centre between Feb. 1 and Mar. 6, 2017, and a convenience sample of eConsults directed to rheumatology between Feb. 1, 2015, and Sept. 30, 2016, through the Champlain BASE eConsult Service, an Ontario-based service. We reviewed all referrals and categorized them by clinical content and question type. A rheumatologist with experience completing eConsult referrals assessed faxed referrals for their suitability to be answered through eConsults. Descriptive statistics were generated. Results We analyzed 300 consecutive faxed referrals and 300 (of 470) eConsult referrals. Faxed questions more often pertained to rheumatoid arthritis (32/300 [10.7%] v. 17/300 [5.7%]), systemic lupus erythematosus (24/300 [8.0%] v. 10/300 [3.3%]), and polyarthritis (30/300 [10.0%] v. 18/300 [6.0%]). eConsults more often addressed abnormal serology without joint symptoms (27/300 [9.0%] v. 8/300 [2.7%]) and gout (15/300 [5.0%] v. 4/300 [1.3%]). Faxed referrals were more likely to have no specific question (116/300 [38.7%]), and eConsults were more likely to have more than 1 question posed (99/300 [33.0%]) and a drug-related question (67/300 [22.3%]). The rheumatologist identified potential benefit from eConsult in 216/300 (72.0%) faxed referrals and 55/59 (93.2%) declined faxed referrals. Interpretation Despite differences in diagnosis between eConsults and faxed referrals, most faxed referrals showed the potential to be addressed through eConsult. Using eConsult may allow primary care providers to obtain answers to questions without requesting a face-to-face specialist referral, or provide support for patients awaiting face-to-face consultation.

Objective Older adults value and benefit from the long-standing relationship they have with their family physicians. This dynamic has not been researched in a long-term care (LTC, ie, nursing home) setting. We sought to determine the proportion of LTC residents who retain their community family physician within the first 180 days of LTC, and the resident, physician, and LTC home factors that may influence retention. Design Population-based retrospective cohort study. Setting and Participants Individuals from Ontario, Canada, aged 60 years or older who were newly admitted to a LTC home between April 1, 2014 and March 31, 2017. Methods Residents were indexed upon LTC admission, and their data was linked across ICES databases. Residents were matched to their rostered family physician, and physician retention was defined as having at least 1 visit by their matched physician within 0 to 90 days and 90 to 180 days of LTC admission. Results Out of 50,089 LTC residents, 12.1% retained their family physicians post-LTC admission. Resident factors associated with reduced odds of retention included physical impairment [odds ratio OR (95% confidence interval, CI) = 0.59 (0.42‒0.83)], cognitive impairment [0.39 (0.33‒0.47)], and a dementia diagnosis [0.80 (0.74‒0.86)]. Physician factors associated with lower retention included a greater distance from the LTC home to the family physician's clinic [30+ kilometers 0.41 (0.35‒0.48)], having a physician who is female [0.90 (0.83‒0.98)], an international medical graduate [0.89 (0.81‒0.97)] or someone who practices in a capitation-based Family Health Organization [0.86 (0.78‒0.95)]. Factors associated with greater odds of retention were residing in a rural LTC home [2.23 (1.78‒2.79)], having a rural family physician [1.70 (1.52‒1.90)], or a family physician who has billed LTC fee codes in the past year [2.64 (2.45‒2.85)]. Conclusions and Implications Few LTC residents retained their family physician post-LTC admission, underscoring this healthcare transition as a breakdown point in relational continuity. Factors that influenced retention included resident health, LTC home geography, and family physician demographics and practice patterns.

In March 2020, the COVID-19 pandemic disrupted competency-based medical education in Family Medicine programs across Canada. Faculty and residents identified a need for clear, relevant, and specific competencies to frame teaching, learning, supervision and feedback during the pandemic.A rapid, iterative, educational quality improvement process was launched. Phase 1 involved experienced educators defining gaps in our program's existing competency-database, reviewing emerging public health and regulatory guidelines, and drafting competencies. Phase 2 involved translation, member-checking, and anonymous feedback and editing of draft competencies by residents and other educational leaders. Phase 3 involved wider dissemination, collaborative editing and feedback from residents and faculty throughout the department.A total of 44 physicians including residents and faculty from multiple contexts provided detailed feedback, review, and editing of an ultimate list of 33 competencies organized by CanMEDS-FM roles. Broad agreement was obtained that the competencies form reasonable learning outcomes during the COVID-19 pandemic.These competencies represent learning objectives reflecting the initial educational mindsets of a wide range of teachers and learners experiencing a global pandemic. The project illustrates a novel collaboration across educational portfolios as a rapid educational response to a public health crisis.En mars 2020, la pandémie de la COVID-19 a perturbé la formation médicale basée sur les compétences des programmes de médecine familiale partout au Canada. Le corps professoral et les résidents ont identifié la nécessité d’avoir des compétences claires, pertinentes et précises pour encadrer l’enseignement, l’apprentissage, la supervision et la rétroaction durant la pandémie.Un processus rapide et itératif d’amélioration de la qualité de l’éducation a été lancé. Au cours de la Phase 1, des éducateurs d’expérience ont identifié les lacunes en lien avec la base de données actuelle des compétences du programme, et fait une ébauche de compétences à partir d’une revue des lignes directrices émergentes en santé publique et des organismes de régulation. La Phase 2 a consisté en la traduction, la révision par les membres ainsi que la rétroaction anonyme et la révision des compétences provisoires par les résidents et autres leaders en éducation. Durant la Phase 3, on a procédé à la diffusion à plus large échelle, à la révision en collaboration et au recueil des commentaires des résidents et du corps professoral dans tout le département.En tout, quarante-quatre (44) médecins comportant des résidents et des membres du corps professoral de multiples contextes, ont fourni une rétroaction détaillée et procédé à l’examen et à la révision d’une liste finale de 33 compétences classées par rôles CanMEDS. Une très vaste majorité a convenu que les compétences produisent des résultats d’apprentissage raisonnables durant la pandémie de la COVID-19.Ces compétences représentent des objectifs d’apprentissage qui reflètent la perspective éducative initiale d’une vaste gamme de d’enseignants et d’apprenants aux prises avec une pandémie mondiale. Le projet représente une nouvelle collaboration entre les programmes d’études comme une réponse éducative rapide à une crise de santé publique.

Background: Effective communication between primary care providers (PCPs) and specialists plays a key role in providing high-quality patient care. A high-quality referral process should involve ref...

Background: When implementing e-health solutions, effective integration into a clinic's existing processes is essential to facilitate adoption and sustained usage. Introduction: This article examines the effectiveness of adoption/utilization of an electronic consultation (eConsult) service by primary care providers (PCPs) using a "delegate model," through which referral clerks manage requests on behalf of PCPs, thereby reducing PCPs' administrative burden. Materials and Methods: We conducted a retrospective cross-sectional study of all eConsults submitted between May 1, 2013, and December 31, 2017, by the Bruyere Academic Family Health Team (FHT), after the clinic implemented the service using a delegate model. We assessed system utilization, including monthly volume of submitted eConsults, requested specialties, and impact on PCP referral behavior based on the mandatory closeout surveys. We also conducted a subanalysis to compare the volumes of eConsults per provider between the FHT and all other providers. Results: The Bruyere Academic FHT submitted 3,233 eConsult cases. Volume increased 3.5 fold, from 285 in the first year to 1,016 in the last year. Active Bruyere Academic FHT providers (those who submitted ≥3 cases in 6 months) submitted a median of 25 eConsults (interquartile range [IQR]: 14.75-35.25) versus 14 (IQR 8-24) for all other active users. In 36% of cases, a referral was originally contemplated but avoided based on specialist advice. In 5% of cases, the referral was not originally contemplated but deemed appropriate by the PCP based on specialist advice. Discussion: Our findings show high levels of eConsult use in the clinic utilizing a delegate model, which persisted throughout the study period and was reported to significantly reduce the backlog of traditional referrals at the clinic. Conclusions: The integration of eConsult capability into existing clinic operations was successful in that it allowed the PCPs to request eConsult using a familiar process, avoiding the challenges associated with adopting a new and unfamiliar technology.

Background: Electronic consultation (eConsult) services have been shown to reduce the need for face-to-face consultations. The largest expense is remunerating the specialist. Introduction: The Cham...

Adherence to antiretroviral therapy (ART) is essential to reduce morbidity and mortality among people living with HIV (PLWH). However, adherence remains suboptimal, and PLWH may benefit from more self-management support to address the complexities of chronic illness. Our objective was to identify the impact of peer-led self-management interventions on adherence and patient-reported outcomes (PROs) among PLWH. We searched MEDLINE, PubMed, Embase, PsycINFO, and CINAHL for English language publications from 1996 to March 2018, and included controlled intervention studies. Additional articles were handsearched, risk of bias assessed, and narrative syntheses outlined. Thirteen studies met inclusion criteria. Findings demonstrate unclear effectiveness for peer-led self-management interventions improving ART adherence; however evidence was limited with only seven studies measuring this outcome and some risk of bias. Many PROs were measured, with limited consistent findings. Future research is needed to strengthen the evidence regarding effects of peer-led self-management interventions on adherence and PROs among PLWH.

People living with HIV on antiretroviral treatment have significantly improved longevity, but as a result may also face increasing multimorbidity due to aging and long-term medication use. Thus, care needs for this population have evolved to require a chronic disease management approach in which self-management plays a central role. Here we highlight the importance of expanding self-management support options for people living with HIV, and discuss strategies for implementing and evaluating self-management interventions, outlining potential opportunities, challenges and solutions. We contend that standardized programs such as those offered through the Self-Management Resource Centre provide a rich opportunity to build the evidence base regarding the potential effectiveness of self-management support among people living with HIV. Thus we recommend enhancing self-management support through meaningful community-level collaboration with people with lived experience, careful assessment of process and outcome factors including who does not participate and why, attention to stigma and the specific needs of HIV priority groups, and consideration of how to extend engagement with services to address social and material needs beyond self-management program participation. We hope this reflection will serve as an aide for researchers and program managers to improve the array of evidence-based self-management support options available to people living with HIV.

Purpose: For people living with HIV (PLWH) using continuous antiretroviral therapy, HIV is now a complex chronic condition often managed in primary care settings. The patient-centered medical home (PCMH) is a model to deliver comprehensive, coordinated, and integrated primary care that promotes collaboration between primary and specialist care and allied services. The study assessed how both Canadian primary and specialist HIV care settings align with the PCMH. Methods: Mixed-methods surveys and interviews with providers in Canadian HIV care settings. Results: Twenty-two settings completed the survey, 12 of which participated in follow-up interviews. Settings had a mean PCMH score of 8.06/12 (SD = 1.53), indicating the basic elements of each PCMH domain have been implemented. We found no significant differences between HIV primary care and specialist care settings. Continuous team-based healing relationships had the highest score (mean = 9.2; SD = 2.15), and quality improvement strategy had the lowest score (mean = 7.19; SD = 2.26). The themes that arose from the interviews were 1) endorsement of the domains of the PCMH by all settings, 2) organizational structures of settings located in hospitals facilitating the implementation of the PCMH through existing technology, patient advisory boards, and accessible services, and 3) dissonance between complex care needs and existing organizational structures in some settings, including limited clinic hours, lack of electronic medical records, and limited mental health services. Conclusions: HIV care in Canada is reasonably well aligned with the PCMH, irrespective of structure of settings. We propose the need for improvements in the use of electronic medical records, quality improvement strategies, and integration of mental health services to achieve better care delivery and health outcomes among PLWH in Canada.

PURPOSE Electronic consultation (eConsult) services can improve access to specialist advice. Little is known, however, about whether and how often primary care clinicians adhere to the advice they receive. We evaluated how primary care clinicians use recommendations conveyed by specialists via the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service and how eConsult affects clinical management of patients in primary care. METHODS This is a descriptive analysis based on a retrospective chart audit of 291 eConsults done between January 20, 2017 and August 31, 2017 at the Bruyere Family Health Team, located in Ottawa, Canada. Patients’ charts were reviewed until 6 months after specialist response for the following main outcomes: implementation of specialist advice by primary care clinicians, communication of the results to the patients, method, and time frame of communication. RESULTS Primary care clinicians adhered to specialist advice in 82% of cases. Adherence ranged from 62% to 93% across recommendation categories. Questions asked by primary care clinicians related to diagnosis (63%), management (27%), drug treatment (10%), and procedures (1%). Recommendations of the eConsult were communicated to patients in 79% of cases, most often by face-to-face visit (38%), telephone call (32%), or use of the patient portal (9%). Communication occurred in a median of 5 days. CONCLUSIONS We found little evidence of barriers to implementing specialist advice with use of eConsult, which suggests recommendations given through service were actionable. With a high primary care clinician adherence to specialist recommendations and primary care clinician–to-patient communication, we conclude that eConsult delivers good-quality care and improves patient management.

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.

Introduction Poor communication between health professionals can compromise patient safety, yet specialists rarely receive feedback on their written communication. Although worldwide implementation of electronic consultation (eConsult) services is rising rapidly, little is known about the features of effective communication when specialists provide online advice to primary care providers (PCP). To inform efforts to ensure and maintain high-quality communication via eConsult, we aim to identify features of high-quality eConsult advice to incorporate into an assessment tool that can provide specialists with feedback on their correspondence. Methods Initial items for the tool were generated by PCPs and specialists using the nominal group technique (NGT). Invited PCPs were above-median eConsult users between July 2016 and June 2017. Specialists were purposively recruited to represent the range of available specialties. Participants individually wrote down items they felt should be included in the tool. A moderator with consensus group expertise then led a round-robin discussion for each item. Items were ranked anonymously and included if highly-ranked by over 70% of participants. Results Eight PCPs (six family physicians, two nurse practitioners) and three specialists (dermatology, hematology, pediatric orthopedics) produced 49 items that were refined to 14 after group discussion and two rounds of ranking. Highly-ranked items encompassed specific, up-to-date, patient-individualized, and practical advice that the PCP could implement. Discussion Features of high-quality eConsult correspondence derived from consensus methods highlight similarities and differences between face-to-face consultation letters and eConsult. Our findings could be used to inform feedback and education for eConsult specialists on their advice to PCPs.

Parkinson’s disease (PD) is a progressive neurological illness that impacts various aspects of life. Integration of medical and self-management in a collaborative approach to care is needed to enhance functioning and the quality of life of PD patients. In developing an integrated care program at a tertiary PD clinic, we used a co-design process to gather stakeholder input. This is a cross-sectional mixed methods study using surveys and interviews. Patient and caregiver participants from the clinic completed two questionnaires to evaluate perceived receipt of self-management support (Patient Assessment of Care for Chronic Conditions) and activation for managing their health condition (Patient or Caregiver Activation Measure®). A subset of these participants and healthcare providers took part in semi-structured interviews. Survey data were described and tested for relationships between patient characteristics and questionnaire scores using Spearman’s rank-order correlation. Interviews were analyzed using conventional content analysis. Fifty-seven PD patients and thirty caregivers completed the questionnaires. Thirteen patients, six caregivers, and six healthcare providers were interviewed. 58% of participants were moderately to highly activated to manage their lives with PD. Participants’ perceptions of self-management support varied but was lacking in dimensions of goal-setting and follow-up support/coordination. Qualitative analysis revealed four overarching themes related to experiences of managing PD: activation, self-management support, coordinated care, and access to services. This first study to explore patient activation in PD found high levels of activation but moderate to low levels of self-management support. The co-design process highlighted important aspects of a more collaborative approach to care.

In 2013, the Living with HIV (LHIV) Innovation team established clinical cohorts of people living with HIV in Manitoba and Newfoundland and Labrador, and they linked the data to provincial health administrative databases. Access to these data enabled researchers to conduct studies across provincial borders; contribute to a national dialogue on HIV health system performance; and give recommendations for evidence-based healthcare, health policy and public health. However, research funding is episodic; maintaining cohorts requires stable funding. We support the establishment of a cross-jurisdictional approach to facilitate streamlined data collection and linkage without interruption and to allow for meaningful analysis in order to inform national policies.

ObjectiveTo provide an overview of the use of and evidence for eConsult in correctional facilities worldwide.DesignScoping review.Data sourcesThree academic databases (MEDLINE, Embase and CINAHL) were searched to identify papers published between 1990 and 2020 that presented data on eConsult use in correctional facilities. The grey literature was also searched for any resources that discussed eConsult use in correctional facilities. Articles and resources were excluded if they discussed synchronous, patient-to-provider or unsecure communication. The reference lists of included articles were also hand searched.ResultsOf the 226 records retrieved from the academic literature search and 595 from the grey literature search, 22 were included in the review. Most study populations included adult male offenders in a variety of correctional environments. These resources identified 13 unique eConsult services in six countries. Six of these services involved multiple medical specialties, while the remaining services were single specialty. The available evidence was organised into five identified themes: feasibility, cost-effectiveness, access to care, provider satisfaction and clinical impact.ConclusionsThis study identified evidence that the use of eConsult in correctional facilities is beneficial and avoids unnecessary transportation of offenders outside of the facilities. It is feasible, cost-effective, increases access to care, has an impact on clinical care and has high provider satisfaction. Some gaps in the literature remain, and we suggest further research on patient satisfaction, enablers and barriers to implementation, and women, youth and transgender populations in this setting to inform service providers and stakeholders. Despite some gaps, eConsult is evidently an important tool to provide timely, high-quality care to offenders.

Objective To compare the content of traditional faxed referrals and electronic consultations (eConsults) and determine how many questions sent by traditional referral could be successfully addressed using eConsult. Methods We conducted a cross-sectional, qualitative study of eConsults and faxed referrals sent to a tertiary diabetes and endocrinology clinic in Ottawa, Ontario. A convenience sample of 300 faxed referrals sent between March and July 2017 and 300 eConsults submitted between January and December 2017 were selected and coded using an established taxonomy to determine question type. Two endocrinologists reviewed the faxed referrals to assess whether they could have been addressed using eConsult. Responses to a mandatory closeout survey were reviewed for all eConsults, assessing the case’s outcome, impact on decision to refer, and educational value. Results Most faxed consultations were requests for shared care in diabetes mellitus, whereas most eConsults requested help in diagnostic test interpretation. 25–27% of faxed consults were felt to be potentially amenable to eConsult. Referring provider behaviour was changed in 45.3% of eConsult cases through avoidance of face-to-face consultation. Conclusion eConsult is a promising tool for PCPs to improve access to specialist opinion without necessitating a face-to-face visit.

High-quality correspondence between healthcare providers is critical for effective patient care. We developed an assessment tool to measure the quality of specialist correspondence to primary care providers (PCPs) via electronic consultation (eConsult), where specialists provide advice without specialist-patient interactions. We incorporated fourteen previously described features of high-quality eConsult correspondence into an assessment tool named the eConsult Specialist Quality of Response (eSQUARE). Six PCPs and two specialists applied the 10-item eSQUARE tool to 30 eConsults of varying quality as informed by PCP survey data. Content, response process, and internal structure validity evidence was gathered. Psychometric properties were calculated using descriptive statistics and generalizability analyses. Mean total score for low-quality eConsults (M = 24 ± 5.6) was significantly lower than moderate-quality eConsults (M = 38 ± 4.7; p

Background: Electronic consultation (eConsult) allows asynchronous virtual communication between primary care providers (PCPs) and specialists regarding patient care. Introduction: The Ontario eConsult Program enables timely and equitable access to specialist advice for Ontarians. This study examines clinicians' perspectives and experiences with the program. Materials and Methods: We conducted an anonymous survey of PCPs registered for the Ontario eConsult Program. The survey ran from June to August 2019 and included questions on PCPs' experiences with the service, opinions on remuneration, and recommendations for enhancement. Results: One thousand two hundred fifty-six PCPs completed the survey (response rate of 16%). Seventy-eight percent had submitted an eConsult, of whom 67% were active users (i.e., had submitted ≥3 eConsults in the past 6 months). The majority of PCPs stated that their user experience was very good (57%) or good (31%), 74% agreed that eConsult improved their referral decision making, and 73% agreed that eConsult increased their ability to manage a broader array of diagnoses. Thirty-seven percent felt adequately compensated for using eConsult, 30% wanted higher rates of remuneration, and 31% were not compensated or were unaware of the fee code. Discussion: The majority of PCPs who use eConsult had positive experiences with the service. Nevertheless, improvements to further streamline the service's use, particularly through electronic medical record integration, were broadly cited as a desirable improvement. Conclusions: PCPs expressed an overall positive experience with the Ontario eConsult Program, citing prompt response times and improved care delivery as chief benefits.

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.

Background Parkinson's disease (PD) is a chronic neurodegenerative disorder that challenges care provision. A multidisciplinary care model needs to be impactful, feasible, and viable economically for widespread utilization. Supportive evidence is lacking. Objective The objective of this study was to evaluate the implementation and impact of a pragmatic network for PD care, the Integrated Parkinson Care Network (IPCN). Methods A 6-month, pre-post design, single-center, phase 2 study for complex interventions for patients with newly diagnosed ( 8 years) PD was used to assess a patient-centered care model based on integrated care, self-management support, and technology-enabled care. We comprehensively assessed the implementation of care paths, change in selected health and care quality outcomes after the Integrated Parkinson Care Network program, and costs analyses. Results We recruited 100 participants in 6 months. Overall, the top care priorities were speech and communication (33.7%), anxiety and depression (31.6%), and mobility, balance, and falls (29.6%), and the most commonly (>45%) used resources were speech-language pathology, community seniors services, and physiotherapy. Care priorities were met successfully in 90.6% of the cases, and there was a positive change in the Parkinson's Disease Questionnaire-8 (2.7; 95% confidence interval, 0.4-5.0; statistically significant in the advanced group), the perception of support for chronic care (Patient Assessment of Chronic Illness Case score, 1.1; 95% confidence interval, 0.9-1.4), and self-management (5As score, 1.2; 95% confidence interval, 1.0-1.4). The total cost of the Integrated Parkinson Care Network was C$1367 per patient. Conclusions A pragmatic development of a care delivery network based on integrated care and self-management support is promising for its feasibility, impact, and a sustainable cost. © 2020 International Parkinson and Movement Disorder Society.

Patients in long-term care (LTC) homes face barriers to accessing specialist advice. Electronic consultation (eConsult) has the potential to improve access for these patients. We used a multi-method approach to evaluate adoption of the Champlain BASE eConsult service in LTC homes across Eastern Ontario, Canada. We conducted a cross-sectional study of all eConsults submitted by primary care providers (PCPs) working at LTC homes between January 1, 2018 and December 31, 2018. Service use data were collected and descriptive statistics were calculated. We completed a thematic analysis of 4 focus groups with PCPs, senior leadership, and a nurse champion working in LTC homes where eConsult is used. Sixty-four cases were submitted to 23 specialty and subspecialty groups by LTC PCPs, most frequently dermatology (19%), geriatric medicine (11%), and infectious disease (9%). Specialists responded in a median of 0.6 days, and 70% of cases were resolved without the resident needing a face-to-face specialist visit. In 60% of cases, PCPs received advice for a new or additional course of action. Participants described complexities in the LTC context, the value of eConsult in LTC, and considerations for implementation. PCPs with experience using the service described increased access to specialist advice, ease of use, and benefits to themselves, residents, and families. eConsult is feasible in LTC and should continue to be used in this region and beyond to improve equity of access to specialist advice. Resolving the identified limitations in LTC, which hinder access to specialists and adoption of eConsult and similar innovations, should be of high priority to researchers and policy makers.

Objectives Selection as a consequence of volunteer participation in, and loss to follow-up from, cohort studies may bias estimates of mortality and other health outcomes. To quantify this potential, we estimated mortality and health service use among people living with HIV (PLWH) who were lost to cohort follow-up (LTCFU) from a volunteer clinical HIV-infected cohort, and compared these to mortality and health service use in active cohort participants and non-cohort-participants living with HIV in Ontario, Canada. Methods We analysed population-based provincial health databases from 1995 to 2014, identifying PLWH ≥ 18 years old; these included data from participants in the Ontario HIV Treatment Network Cohort Study (OCS), a volunteer, multi-site clinical HIV-infected cohort. We calculated all-cause mortality, hospitalization and emergency department (ED) visit rates per 100 person-years (PY) and estimated hazard ratios (HRs) of mortality, adjusting for age, sex, income, rurality, and immigration status. Results Among 23 043 PLWH, 5568 were OCS participants. Compared with nonparticipants, participants were younger and less likely to be female, to be an immigrant and to reside in a major urban centre, and had lower comorbidity. Mortality among active participants, participants LTCFU and nonparticipants was 2.52, 3.30 and 2.20 per 100 PY, respectively. After adjustment for covariates, mortality risk was elevated among participants LTCFU compared with active participants (HR 2.26; 95% confidence interval 1.91, 2.68). Age-adjusted hospitalization rates and ED visit rates were highest among participants LTCFU. Conclusions Mortality risk and use of health care resources were lower among active cohort participants. Our findings may inform health outcome estimates based on volunteer cohorts, as well as quantitative bias adjustment to correct for such biases.

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.

Standardized self-management supports are an integral part of care delivery for many chronic conditions. We used the validated Patient Activation Measure (PAM®) to assess level of engagement for self-management from a sample of 165 people living with HIV (PLWH) and 163 people with diabetes. We conducted multivariable logistic regression to assess associations between demographics and PAM® scores. PLWH had high levels of activation that were no different from those of people with diabetes (mean score = 67.2, SD = 14.2 versus 65.0, SD = 14.9, p = 0.183). After adjusting for patient characteristics, only being on disability compared to being employed or a student was associated with being less activated (AOR = 0.276, 95%CI = 0.103-0.742). Our findings highlight the potential for the implementation of existing standardized chronic disease self-management programs to enhance the care delivery for PLWH, with people on disability as potential target populations.

Background Wait times for gastroenterologists in Canada continue to exceed recommended targets. Electronic consultation (eConsult) may reduce the need for face-to-face gastroenterologist visits. Objective The goal of this study was to identify the cases submitted to gastroenterologists though the Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service and explore their impact on primary care physicians’ (PCPs) courses of action. Methods Gastroenterology cases submitted between June 2013 and January 2015 were categorized using a modification of the International Classification for Primary Care (ICPC-2) taxonomy. Question type (e.g., diagnosis or management) was classified using a validated taxonomy. Results Of the 121 gastroenterology consults reviewed, 33% were related to hepatology, 23% to GI symptoms, and 13% to specific luminal diseases. Among hepatology eConsults (n=40), 47% pertained to abnormal liver function testing. Overall, 51% of eConsults were related to diagnosis, 30% to management, 9% to drug treatments and 7% to procedures. PCPs received a reply within a median of 2.9 days. Only 25% of cases resulted in a face-to-face referral. Conclusions The eConsult service provided timely, highly regarded advice from gastroenterologists directly to PCPs and often eliminated the need for a face-to-face consultation. An evaluation of the most commonly-posed questions could inform future continuing medical education activities for PCPs.

Background: Health technology solutions are too often implemented without a true understanding of the system-level problem they seek to address, resulting in excessive costs, poor adoption, ineffectiveness, and ultimately failure. Before implementing or adopting health care innovations, stakeholders should complete a thorough assessment to ensure effectiveness and value. In this article, we describe how to evaluate the impact of a health technology innovation through the 4 dimensions of care outlined by the Quadruple Aim Framework, using our experience with the Champlain Building Access to Specialists through eConsultation (BASE) eConsult service as a case example. Methods: A descriptive overview of data was collected between April 1, 2011, and August 31, 2017, using 4 dimensions of care outlined by the Quadruple Aim Framework: patient experience, provider experience, costs, and population health. Findings were drawn from use data, primary care provider closeout surveys, surveys/interviews with patients and provider, and costing data. Results: Overall, patients have received access to specialist advice within days and find the advice useful in 86% of cases. Provider experience is very positive, with satisfaction ratings of high/very high value in 94% of cases. The service cost a weighted average of $47.35/case, compared with $133.60/case for traditional referrals. In total, 1,299 primary care providers have enrolled in the service, completing 28,838 cases since 2011. Monthly case volumes have grown from an average of 13 cases/month in 2011 to 969 cases/month in 2016. Conclusions: The eConsult service has been widely adopted in our region and is currently expanding to new jurisdictions across Canada. However, although we successfully demonstrated eConsult9s impact on patient experience, provider satisfaction, and reducing costs, we met several challenges in evaluating its impact on population health. More work is needed to evaluate eConsult9s impact on key population health metrics (eg, mortality, morbidity, and system use). Efforts to conduct such evaluations are underway.

Timely presentation to care for people newly diagnosed with HIV is critical to optimize health outcomes and reduce onward HIV transmission. Studies describing presentation to care following diagnosis during a hospital admission are lacking. We sought to assess the timeliness of presentation to care and to identify factors associated with delayed presentation. We conducted a population-level study using health administrative databases. Participants were all individuals older than 16 and newly diagnosed with HIV during hospital admission in Ontario, Canada, between April 1, 2007 and March 31, 2015. We used modified Poisson regression models to derive relative risk ratios for the association between sociodemographic and clinical variables and the presentation to out-patient HIV care by 90 days following hospital discharge. Among 372 patients who received a primary HIV diagnosis in hospital, 83.6% presented to care by 90 days. Following multivariable analysis, we did not find associations between patient sociodemographic or clinical characteristics and presentation to care by 90 days. In a secondary analysis of 483 patients diagnosed during hospitalization but for whom HIV was not recorded as the principal reason for admission, 73.1% presented to care by 90 days. Following multivariable adjustment, we found immigrants from countries with generalized HIV epidemics (RR 1.265, 95% CI 1.133-1.413) were more likely to present to care, whereas timely presentation was less likely for people with a mental health diagnosis (RR 0.817, 95% CI 0.742-0.898) and women (RR 0.748, 95% CI 0.559-1.001). Future work should evaluate mechanisms to facilitate presentation to care among these populations.

PURPOSE Excessive wait times for specialist appointments pose a serious barrier to patient care. To improve access to specialist care and reduce wait times, we launched the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service in April 2011. The objective of this study is to report on the impact of our multiple specialty eConsult service during the first 5 years of use after implementation, with a focus on growth and sustainability. METHODS We conducted a cross-sectional study of all eConsult cases submitted between April 1, 2011 and April 30, 2016, and measured impact with system utilization data and mandatory close-out surveys completed at the end of each eConsult. Impact indicators included time interval to obtain specialist advice, effect of specialist advice on the primary care clinician’s course of action, and rate of avoidance of face-to-face visits. RESULTS A total of 14,105 eConsult cases were directed to 56 different medical specialty groups, completed with a median response time of 21 hours, and 65% of all eConsults were resolved without a specialist visit. We observed rapid growth in the use of eConsult during the study period: 5 years after implementation the system was in use by 1,020 primary care clinicians, with more than 700 consultations taking place per month. CONCLUSIONS This study presents the first in-depth look at the growth and sustainability of the multispecialty eConsult service. The results show the positive impact of an eConsult service and can inform other regions interested in implementing similar systems.

Accessing healthcare can be difficult but the barriers multiply for people living with HIV (PLHIV). To improve access and the health of PLHIV, we must consider their perspectives and use them to inform standard practice. A better understanding of the current literature related to healthcare access from the perspective of PLHIV, can help to identify evidence gaps and highlight research priorities and opportunities. To identify relevant peer-reviewed publications, search strategies were employed. Electronic and grey literature databases were explored. Articles were screened based on their title and abstract and those that met the screening criteria, were reviewed in full. Data analysis was conducted using a collaborative approach that included knowledge user consultation. Initial concepts were extracted, summarized and through framework synthesis, developed into emerging and final themes. From 20,678 articles, 326 articles met the initial screening criteria and 64 were reviewed in full. The final themes identified, in order of most to least frequent were: Acceptability, Availability, Accessibility, Affordability, Other Barriers, Communication, Satisfaction, Accommodation, Preferences and Equity in Access. The most frequently discussed concepts related to negative interactions with staff, followed by long wait times, limited household resources or inability to pay fees, and fear of one's serostatus being disclosed. Knowledge users were in agreement with the categorization of initial concepts and final themes; however, some gaps in the literature were identified. Specific changes are critical to improving access to healthcare for PLHIV. These include improving availability by ensuring staff and healthcare professionals have proper training, cultivating acceptability and reducing stigma through improving HIV awareness, increasing accessibility through increased HIV information for PLHIV and improved dissemination of this information to increase patient knowledge and health awareness. Finally, ensuring proper protocols are implemented and followed to guarantee patient confidentiality and overall satisfaction with healthcare services are recommended.

Introduction Excessive wait times for chronic pain are associated with significant reductions in quality of life and worse health outcomes. The Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service can improve access to specialist care for patients with chronic pain by facilitating electronic communication between primary care providers (PCPs) and specialists. We explored the content of eConsult cases sent to chronic pain specialists to identify the major themes emerging from exchanges between PCPs and specialists regarding patients with chronic pain. Methods We conducted a thematic analysis of eConsult cases submitted to chronic pain specialists between April 1, 2011 and October 31, 2014, using a constant comparison approach. Results PCPs submitted 128 cases to chronic pain specialists during the study period. The study team coded 48 cases before data saturation was reached. PCPs sought advice for treating patients with chronic pain arising from a range of medical problems, and who frequently struggled with issues of mental health, substance dependence, and social complexity. Specialists responded with advice on pain management and treatment, directed PCPs to published guidelines and community resources, and validated the PCPs' frustration or concerns. Specialists provided instruction on safe opioid prescribing and how to identify and manage potential cases of substance dependence. Conclusion Providing care to patients with chronic pain is a challenge for PCPs, who often experience frustration at their inability to provide a definitive solution for patients. Specialists offered invaluable feedback not only through guidance and advice, but also with sympathy and encouragement.

Background Transient ischemic attack (TIA) is a strong predictor of subsequent stroke. Measures to decrease stroke incidence following TIA include medical management, risk factor optimization, and lifestyle modification. Best practice recommendations for stroke care promote individualized education on self-management across transitions from hospital to community settings. In the study region, patients with TIA are referred to the stroke prevention clinic where they receive rapid stroke assessment, risk factor management, education, and referral to risk reduction programs. Long-term management is typically the responsibility of primary care providers who may have limited resources for self-management support. Promotion of existing chronic disease self-management (CDSM) programs can complement this support. Objective The objective of our project was to examine the feasibility and acceptability of an electronic referral system to an existing CDSM program to facilitate self-management support for persons with TIA. Methods We performed a descriptive evaluation of a quality improvement project that involved development and implementation of a new electronic referral (eReferral) process. A partnership between the stroke prevention clinic and the regional Living Healthy CDSM program was developed alongside a clinical information system redesign implementing an eReferral system. Results Referral to the Living Healthy CDSM program was offered to each patient at the stroke prevention clinic. Of 912 patients seen over a 6-month period, 62 (7%) agreed to be referred. Of these, 23 (37%) were registered or waitlisted. Conclusion Formation of a partnership and implementation of the eReferral system facilitated referral to the Living Healthy CDSM program. Despite low referral and enrollment rates, the eReferral system provides one option to enhance self-management support for persons with TIA.

Objective.To describe the use and benefits of an innovative eConsult service to improve access to rheumatologists.Methods.There were 225 eConsults directed to rheumatology that were categorized by type of question and effect on face-to-face referral rates.Results.The median response time by the rheumatologists was 1.9 days. Clinical questions included drug treatment (34%), diagnosis (26%), or management (14%). Osteoporosis was the most common diagnosis (22%), followed by pain in multiple joints (11%), and polyarthritis (10%). A face-to-face referral was avoided in 38% of cases.Conclusion.There are clinical questions that can be answered quickly by an eConsult, improving access to rheumatologists.

Background and Aims Chronic pain is a debilitating condition that requires prompt access to care for effective treatment. Wait times for care often exceed benchmark recommendations, with potential consequences to patient health outcomes. The goal of this paper is to gain the perspectives of patients attending a chronic pain clinic regarding the acceptability of current wait times and the impact of their experiences of waiting for chronic pain care. Methods The study took place in a chronic pain clinic at an academic-affiliated teaching hospital in Ottawa, Canada, which housed seven clinicians at the time of the study. New patients attending the chronic pain clinic between July 14, 2014 and August 5, 2015 were eligible to participate based on the availability of the research and clerical staff who administered the survey on a variety of days over the course of the study. Patients completed a self-administered 29-item survey. The survey took approximately five to ten minutes to complete. Questions pertained to patients’ socioeconomic factors, chronicity and burden of pain symptoms, and satisfaction with current wait times. Actual wait times were self-reported. Survey results were entered into an Excel spreadsheet, exported to SPSS, and coded numerically to facilitate descriptive analyses using comparative graphs and tables. Open-text responses were reviewed by the authors. Results Sixty-six patients completed the survey. While 83% of patients stated that their ideal wait time was less than three months, 32% reported receiving an appointment within this period, and 31% reported waiting a year or more. Only 37% of patients felt the wait time for their appointment was appropriate. During their wait,41% of patients reported receiving written information about chronic pain and 47% were referred to a local chronic pain management group. 94% reported interference with social/recreational activities and normal activities of daily living, 31% had to miss work or school due to the frequency of ongoing symptoms, and 22% reported being unable to attend work or school altogether. Furthermore, 37% of patients reported visiting the emergency room within the previous year and 65% worried about having a serious undiagnosed disease. Conclusions Our study found that wait times for chronic pain care, even those triaged as urgent cases, far exceeded what patients considered ideal. Only a third of patients received care within three months of making their appointment, while nearly another third waited over a year. During the waiting period, nearly all patients experienced some impact on their day-to-day activities and work or school attendance, half were unemployed, and nearly a quarter reported a complete inability to attend work or school because of pain. Implications Wait times for chronic pain care exceed timelines deemed acceptable by patients, causing anxiety and reducing function. The patient perspective must be considered in initiatives attempting to improve access to care for this population with specific needs and goals. Innovative solutions, such as electronic consultation and shared care models, hold promise.