Sustainability of a Primary Care–Driven eConsult Service

The purpose of this study is to study the effect of an e-consult system in reducing the long waiting times that Canadian patients face when trying to see specialists. The overall goals were to reduce unnecessary referrals, decrease time from referral with specialist to consult, and to improve patient satisfaction.

The authors used a cross sectional study across Ontario, and included anyone who was registered in this e-consult service for a 5 year period. An impact analysis survey was sent to providers using the e-consult service to see if using the e-consult service changed their overall course of action. This system is different than other systems, because the patient is referred to the service, and then the patient is triaged by a person who is not their primary physician to an appropriate doctor, and therefore a specific specialist cannot be chosen. There were a lot of questions in the group about how this triage actually took place and how payment worked for the consult system. There were also doubts on if this was purely a consult service or a referral service. If it was both, were specialists doing the consult able to self refer, because if so, that would present a conflict of interest.

There were a lot of NPs who used this system and there were questions on what the scope of practice is for NPs in Canada and if these NPs were first consulting a physician before using the e-consult system. The group also noted that the majority of people using the service reported a response time of <10mins and questioned how such a quick response time was possible. It was also noted that while the number of consults increased steadily across the board there was an even greater number of doctors who joined the e-consult system but did not use the service. The following were data elements that the authors did not report on that the group wanted information on: doctor satisfaction, patient satisfaction, what prompted use of the system, if doctors were using other means outside of the e-consult system for consults, if referrals were made outside of the system, and the time it took to get from referral to seeing a specialist. The group argued that since the goal of this study is to decrease clog in the system for referrals, knowing about what doctors are doing outside of the system could help determine if the e-consult service is actually effective.

The group felt that data in Figure 2a could have been presented in a better way. Given the large differences in the number of physicians in each specialty group, the scale used did not provide a good comparison. There was also a discussion on how specialists were able to get on the list for e-consult services and whether or not there was a way to select subspecialists within the e-consult system.

The group discussed the policy implications of the study. There are more primary care doctors than specialists in Canada. This is in stark contrast to the U.S. where there is a shortage of primary care physicians. The student group discussed whether or not this study would be practical in the US due to the fact that the hospital systems in America do not follow the same model as in Canada. While this study may be generalizable to larger regions and territories in Canada, the group argued whether or not this e-consult system would be helpful in the US where the system is completely different. There is also a legal aspect in the US, which may not be a problem in Canada. The question discussed was who would bear the liability if the consult resulted in a lack of referral in a patient who needed one. In Canada, because healthcare is universal, there is not as big of an issue with medical lawsuits, however malpractice cases in the US is a big worry for many physicians, and doctors in the US may be wary of using this system if the legal liability was not spelled out explicitly.

Another potential problem raised about this study was its ability to be integrated with telemedicine, and whether or not patients would be comfortable with consulting a specialist using a e-consult service. Some patients, especially in America, value their ability to choose their doctor dependent on specialty, and this system might remove some of that independence. However, other patients might really value this system because they may appreciate not having to drive a greater distance to see a specialist. Much of a patient's ability to choose is dependent on the type of insurance that they have in America. This is not a problem that patients in Canada have to deal with. The group also felt that there were outcomes missing in this study.

Overall the group felt that the study made a good attempt in trying to address an issue that patients face in Canada and that with more data this program could potentially expand to other territories there. For this type of program to be expanded to the U.S. however, more research would need to be done, and it would need to be strategically placed in an area where patients would feel comfortable with their doctors using an e- consult system

Competing interests: None declared