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 catego - rized 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% per - tained 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 gastroenterolo - gists 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. Keywords: Access to care; eConsult; Wait times Virtual consultations such as telemedicine (where the pro- INTRODUCTION vider connects to a patient remotely) and eConsult (where the Access to specialty care remains a challenge in Canada, where referring provider ask a patient-specific question to a specialist patients frequently face long wait times for specialist appoint- through a secure server) have been demonstrated to reduce the ments. Primary care providers (PCPs) often cite gastroenter - need for patients to ae tt nd an in-person specialist visit.(1, 2) ology as a high-demand specialty,(1, 2) and consequently, Within gastroenterology, telemedicine has been used primarily wait times for gastroenterologist appointments regularly for patients with hepatitis C and inflammatory bowel disorders. exceed recommended benchmarks, which range from two (4, 5) There is one report from the Mayo Clinic that reported weeks to two months depending on the condition.(3) New on gastroenterology eConsults occurring within the organiza- solutions are needed to improve access to advice from gas- tion. They demonstrated that, of the 901 eConsults submitted, troenterologists for patients in a time frame supported by ex- only 160 required a face-to-face visit.(2) Providers have noted isting guidelines. © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 124 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact email@example.com Downloaded from https://academic.oup.com/jcag/article-abstract/1/3/124/4998437 by guest on 17 October 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 3 125 that eConsults have an added benefit beyond reducing the e ch Th amplain BASE™ eConsult service number of patient visits by serving as an educational tool for The Champlain BASE™ eConsult service, established in 2010, PCPs, as the answers they receive can inform the care they pro- uses a secure web-based platform through which PCPs (fam- vide for other patients and lead to discussions with peers about ily physician or nurse practitioner) can submit a patient-spe- similar cases.(6) Building capacity within primary care on com- cific clinical question to over 100 different specialty services. mon referral scenarios can help reduce the number of referrals Gastroenterology was added to the service June 2013.(8) PCPs to subspecialty services, thus increasing time for more urgent can aa tt ch supplementary investigations such as laboratory or consultations and sicker patients.(7) imaging results that may be relevant to the question asked. The The objective of this study was to 1) describe the utilization specialist receives notification of the pending case via email and impact of gastroenterology eConsults submitted through and has seven days to respond following the initial email noti- the Champlain BASE™ (Building Access to Specialists through fication. The specialist responds through the same secure web- eConsultation) eConsult service and 2) determine the types of based platform by providing clinical advice, requesting further questions most commonly asked by PCPs. information or recommending a face-to-face consultation. This dialogue continues until the PCP closes the case. In order to close a case, the PCP must complete a brief survey assessing METHODS the case’s outcome and perceived value for the patient and PCP Study design (Figure 1). Specialists are remunerated at $200 CAD per hour We conducted a cross-sectional study of all eConsult cases sub- prorated to their self-reported time spent answering the case. mitted to gastroenterologists between June 2013 and January We calculated the costs paid to the specialist for eConsults and 2015. The University of Ottawa Research Ethics Board pro - compared those to payment for a face-to-face referral based on vided full approval for this study. the current Ontario fee schedule ($157 per consult seen). Setting Data collection and analysis The Champlain BASE™ eConsult service is based in the The eConsult service automatically collects utilization data Champlain Local Health Integration Network (LHIN), a health for each case, including PCP type (family doctor versus nurse region in eastern Ontario. The Champlain LHIN has a popula - practitioner), patient age and gender, specialty referred to, and tion of 1.2 million, roughly half of which resides in the region’s specialist self-reported response time. Additionally, the service main metropolitan centre (Ottawa) and half in the surrounding saves a complete log of all exchanges between PCPs and special- communities and rural areas up to two hours away by car. ists, with timestamps indicating when each exchange was sent. Q1: Which of the following best describes the outcome of this eConsultation for your patient? 1) I was able to confirm a course of action that I originally had in mind 2) I got new advice for a new or additional course of action 3) I did not find the response very useful 4) None of the above Q2: As a result of the eConsultation would you say that: 1) Referral was originally contemplated but now avoided at this stage 2) Referral was originally contemplated and is still needed –this eConsult likely leads to a more effective visit 3) Referral was not originally contemplated and is still not needed –this eConsult provided useful feedback/instruction 4) Referral was not originally contemplated, but eConsult process resulted in a referral being initiated 5) There was no particular benefit to using eConsult in this case 6) Other (please explain) Q3: Please rate the overall value of the eConsult service for your patient: Minimal 1 2 3 4 5 Excellent Q4: Please rate the overall value of the eConsult service in this case for you as a primary care provider: Minimal 1 2 3 4 5 Excellent Q5: We would value any additional feedback you provide: Figure 1. Closeout survey administered upon completion of each eConsult. Downloaded from https://academic.oup.com/jcag/article-abstract/1/3/124/4998437 by guest on 17 October 2018 126 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 3 PCP feedback is collected via the mandatory closeout survey. All data were exported into an Excel database for analysis. We identified all cases submitted to gastroenterology during the study period. All cases were received and responded to by a single gastroenterologist at our institution who has been in practice for over 10 years. Descriptive analyses were used to quantif y the most common clinical topics and question types. All cases between June 2013 and January 2015 were reviewed retrospectively for gastroenterology content using a predefined list of clinical diag - noses, which was generated by consensus using a modification of the International Classification for Primary Care (ICPC-2) tax - onomy. Each question was also classified by the type of question Figure 2. Specialists’ self-reported response times for eConsult cases. (e.g., diagnosis or management) using a validated taxonomy.(9) To ensure agreement on categorization, the first 20 eConsults were coded by the resident (SC) and reviewed with the special- patients, with PCPs identifying that in 80 (66%) of cases, the ist (NS). Any disagreements were resolved through re-reviewing PCP identified that they received advice for a new or additional and discussing the eConsult in detail. To examine eConsult’s course of action. There was significant impact on PCP intention impact on referral behaviour, we collected PCPs’ responses to the to refer the patient for a face-to-face referral. mandatory closeout survey for all gastroenterology cases. In 51 (42%) cases, a referral was originally contemplated, but ultimately avoided. In 31 (26%) cases, a referral was not orig- inally contemplated and was still not needed. Overall, 68% of RESULTS all completed cases did not require a face-to-face visit. In 32 Between June 24, 2013 (when GI was added as an eConsult (26%) cases, a referral was originally contemplated and was specialty) and January 31, 2015, 1264 cases were completed still needed, but the PCP perceived that eConsult would lead through the Champlain BASE™ service, of which 184 (14.5%) to a more effective specialist visit. In 4 (3%) cases, a referral was were directed to gastroenterology. A subset of 100 to 120 cases not originally contemplated, but eConsult process resulted in a was deemed sufficient for the analysis, and as such, 121 cases referral being initiated. The total cost of specialist payment for were coded. eConsult was $6599. The cost for face-to-face visits if eConsult Of the 121 cases included in the study, 113 (93%) were com- was not available would have been $13,031 (83 patients at $157 pleted by family physicians and 8 (7%) by nurse practitioners. each) compared with $5495 (36 patient at $157 each) ae ft r an PCPs received a reply within a median of 2.9 days. The time the eConsult. Thus, the overall cost with eConsult and subsequent gastroenterologist self-reported for completing the case was less face-to-face visits was $12,094, compared with anticipated than 10 minutes in 16 (8%) cases, 10–15 minutes in 60 (50%) $13,031 if eConsult was not available. We did not calculate cases, 15–20 minutes in 41 (34%) cases and over 20 minutes in costs to the patient or other indirect costs. 4 (3%) of cases (Figure 2). The average specialist payment was $54.53 per consult. DISCUSSION Of the 121 gastroenterology consults reviewed, 33% were related to liver issues, 23% to gastrointestinal (GI) symptoms Given the increasing challenges gastroenterologists face in and 13% to specific luminal diseases ( Table 1). Of the liver-re- meeting benchmark wait times for care, eConsult offers an lated eConsults, 47% were specifically regarding abnormal liver opportunity to reduce the number of face-to-face visits required. enzyme tests. Imaging findings were also common, with 15% of (3) Champlain BASE™ is the first eConsult service in Canada cases for fatty liver and 10% for liver nodules. Among eConsults to include gastroenterology among its available specialties and for GI symptoms, the most common questions regarded gastro- has demonstrated the ability to provide PCPs and their patients esophageal reflux disease (30% of GI symptom questions) and with quick access to high-quality advice on gastroenterologi- abdominal pain (24%). cal issues, often without the need of a face-to-face visit with a Question type related to diagnosis in 51% of cases, manage- specialist. W hile eConsult has the potential to reduce costs at a ment of a disease/symptoms in 30%, drug treatments in 9%, system level by avoiding unnecessary referrals, it can also have and procedures in 7%. Of the procedural-related questions, the a positive economic impact on a patient level, since by avoiding majority (78%) were regarding colonoscopy. unnecessary referrals, patients are able to avoid missing work Based on the end of consult survey, PCPs reported the ser- or school or paying travel costs associated with specialist vis- vice as high or very high quality for them and their patient in its. These costs can be significant for patients in rural areas who 97% of cases. The eConsult changed the clinical course of many must travel great distances for specialist care.(1, 10) Downloaded from https://academic.oup.com/jcag/article-abstract/1/3/124/4998437 by guest on 17 October 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 3 127 Table 1. eConsults to GI specialists by question category (n=121) communication between patients and gastroenterologists directly by connecting both parties via email or telephone, a Category N % of situation most common for patients with chronic diseases who Category require regular follow-up with GI specialists.(11) Numerous Hepatology (n = 40) studies have examined telephone consultations as an alternative Liver Abnormal LFTs NOS 23 58% to face-to-face consultations with gastroenterologists, noting Hepatomegaly 1 3% that remote consultations improved overall quality of follow-up Fatty Liver 6 15% care, reduced nonae tt ndance rates and shorter wait times for Liver Cirrhosis 1 3% urgent appointments.(12–14) Although a number of studies Haemachromatosis 1 3% have established eConsult’s ability to improve access, reduce Low Ceruloplasmin 1 3% need for face-to-face referrals, provide high levels of provider Hepatitis B 1 3% satisfaction and lower costs,(15, 16) there is only one study that Hepatitis C 2 5% specifically reports on gastroenterology eConsults. This study Liver nodule/Lesion 4 10% was conducted at the Mayo Clinic, where the referring and spe- Luminal GI (n = 26) cialist providers’ access to the same EMR was established not Celiac disease/gluten sensitivity 7 27% to reduce wait times, but rather to improve efficiencies. Despite IBD 2 8% differences with the Champlain BASE™ model, the Mayo Clinic Barrett’s Esophagus 1 4% service demonstrated a similar savings in face-to-face refer- Esophageal Disease 1 4% rals, with only 18% of the cases being converted to a face-to- Recurrent Bowel Obstruction 1 4% face consultation. The most common clinical questions asked H. Pylori 5 19% through the Mayo Clinic service were cancer screening, image Anal Fissure/Perianal Abscess 1 4% interpretation, interpretation of lab results and procedure ques- IBS 6 23% tions. The differences between the most common questions Colonic Polyps/Colorectal Cancer 1 4% compared to our study may be due in part to the varying roles GI Cancer 1 4% of PCPs in each system and to a restriction placed on ‘orderable’ GI Symptoms (n = 33) eConsults through the Mayo Clinic electronic medical record. Gastroesophageal reflux disease 10 30% W hile the Champlain BASE™ eConsult service was designed Abdominal first and foremost to improve patients’ access to specialist pain/Cramps 8 24% advice, its ability to foster two-way communication between Chronic Diarrhoea 5 15% PCPs and specialists has had the unintentional benefit of sup - Constipation 2 6% porting PCP learning. In a recent analysis of PCPs’ open text Rectal/Anal Pain 3 9% responses to the mandatory closeout survey, eConsult’s ability Fecal Incontinence 1 3% to serve as an educational tool emerged as a frequent theme.(6) Belching 1 3% Many PCPs noted that the advice they received from specialists Easy Gagging 1 3% was applicable to multiple cases and would likely improve their Weight gain 1 3% ability to treat future patients with similar conditions. Our find - Dyspepsia/Indigestion 1 3% ings suggest that such learning could reduce the need for gastro- Procedures (n = 9) enterology referrals: one-third of the cases in our study were for Screening Colonoscopy 7 78% hepatology concerns, the majority of which involved identifica - Colonoscopy 1 11% tion of abnormal liver enzymes, a process that could easily be PEG 1 11% carried out by the PCP without necessitating a face-to-face spe- Other (n = 7) cialist referral. By identif ying the most frequent questions PCPs Gallbladder polyps 2 29% pose to various specialties, eConsult could help guide future Pancreatic disease 1 14% continuing medical education curricula and ensure PCPs are Zinc Deficiency 1 14% receiving education on topics relevant to their patients’ needs. Periumbilical Ecchymoses 1 14% Our study is somewhat limited by the small sample size and Use of NSAID in post = gastric bypass 1 14% focus on one geographical region. We have since expanded our Anaemia 1 14% eConsult service to different jurisdictions within Ontario and other provinces. We hope to be able to demonstrate more gen- Healthcare providers have evaluated a number of different eralizability in future studies. It is too early to determine if the methods for reducing the need for face-to-face visits in gas- availability of an eConsult service will significantly impact wait troenterology. One such model involves allowing electronic times. We do not collect patient identifiers and thus cannot Downloaded from https://academic.oup.com/jcag/article-abstract/1/3/124/4998437 by guest on 17 October 2018 128 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 3 track individual patient outcomes. This is an important outcome 5. Aguas M, Del Hoyo J, Faubel R, et al. Telemedicine in inflam- matory bowel disease: Opportunity ahead. Inflamm Bowel Dis which we will be studying in future projects. We are unable to 2016;22(2):E4–5. compare our outcomes of traditional referrals. 6. Liddy C, Afkham A, Drosinis P, et al. Impact and satisfaction with a new eConsult service: A mixed methods study of primary care CONCLUSIONS providers. J Am Board Fam Med 2015;28(3):394–403. 7. Mata-Roman L, del Olmo-Martinez L, Briso-Montiano R, et al. The eConsult service provided timely, highly regarded advice Periodic gastroenterology and hepatology meetings with primary from gastroenterologists directly to PCPs and often elimi - care. Reasons for consultation. Revista Espanloa De Enfermedades nated the need for a face-to-face consultation. With limited Digestivas 2013;105(9):521–8. resources and access to gastroenterologists across Canada, 8. Keely E, Liddy C, Afkham A. Utilization, benefits, and impact of an eConsults provide a means to assist patient care provided by e-Consultation service across diverse specialties and primary care PCPs. Unnecessary referrals are avoided, which should result providers. Telemed J E Health 2013;19(10):733–8. in reducing wait times for more urgent referrals. Commonly 9. Ely JW, Osheroff JA, Gorman PN, et al. A taxonomy of generic clin- recurring questions can be used to inform planning of future ical questions: Classification study. BMJ 2000;321(7258):429–32. continuing professional development events. 10. Liddy C, Drosinis P, Deri Armstrong C, et al. What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluation. BMJ Acknowledgements Open 2016;6(6):e010920. This work was supported by the Royal College of Physicians and 11. Plener I, Hayward A, Saibil F. E-mail communication in the man- Surgeons of Canada, Department of Medicine University of Ottawa, agement of gastroenterology patients: A review. Can J Gastroenterol Ontario Ministry of Health and Long-Term Care, The Ottawa Hospital Hepatol 2014;28(3):161. Academic Medical Organization Innovation Fund, e-Health Ontario, 12. Akobeng AK, O’Leary N, Vail A, et al. Telephone consultation as a and the Champlain Local Health Integration Network. substitute for routine out-patient face-to-face consultation for chil- dren with inflammatory bowel disease: Randomised controlled trial and economic evaluation. EBioMedicine 2015;2(9):1251–6. References 13. Gethins S, Robinson R , de Caestecker J, et al. Impact of a nurseGêÆ 1. Kirsh S, Carey E, Aron DC, et al. Impact of a national specialty led telephone clinic on quality of IBD care. Gastrointestinal e-consultation implementation project on access. Am J Managed Nursing 2007;5(1):34–9. Care 2015;21(12):e648–54. 14. Miller L, Caton S, Lynch D. Telephone clinic improves qual- 2. North F, Uthke LD, Tulledge-Scheitel SM. Internal e-consul- ity of follow-up care for chronic bowel disease. Nursing Times tations in an integrated multispecialty practice: A retrospec- 2001;98(31):36–8. tive review of use, content, and outcomes. J Telemed Telecare 15. Liddy C, Drosinis P, Keely E. Electronic consultation systems: 2015;21(3):151–9. Worldwide prevalence and their impact on patient care: A system- 3. Leddin D, Bridges RJ, Morgan DG, et al. Survey of access to gas- atic review. Fam Pract 2016;33(3):274–85. troenterology in Canada: The SAGE wait times program. Can J 16. Vimalananda VG, Gupte G, Seraj SM, et al. Electronic consul- Gastroenterol Hepatol 2010;24(1):20–5. tations (e-consults) to improve access to specialty care: A sys- 4. Siegel CA. Transforming gastroenterology care with telemedicine. tematic review and narrative synthesis. J Telemed Telecare Gastroenterol 2017;152(5):958–63. 2015;21(6):323–30.
Journal of the Canadian Association of Gastroenterology – Oxford University Press
Published: Sep 12, 2018
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