An Ottawa area pilot project that facilitates electronic consultations between family physicians and specialists has proved so popular among doctors and administrators that its architects are finding ways to make it permanent. These consultations occur before an actual referral to a specialist is considered by the family doctor.

“Doing referrals as a family doctor is one of the most frustrating, very stressful things, because you are always worrying,” says Clare Liddy, an Ottawa family doctor and investigator with the Bruyère Research Institute. Worries may include: Will the referral meet the patient’s needs? Will the physician see the patient in a timely manner? Can anything be done to better manage the patient in the meantime?

Using e-consultations, Liddy has heard back in as few as 24 hours from specialists who have provided suggestions such as what therapy she might try with a patient and/or what tests she should consider ordering.

Average response time is two days

The project’s general expectation is that the family doctors will receive a response from specialists within a week; the average time has been two days and the median response time has been less than a day.

At the Champlain Local Health Integration Network (LHIN), the focus is on e-consultations between family doctors and specialists that take place before a possible referral. Projects exploring the use of e-referrals (when a doctor arranges for a patient to see a specialist) are underway at neighbouring LHINs, says Glenn Alexander, Chief Information Office for both the Champlain and the Southeast LHIN.

Liddy spearheaded the project, which was launched in early 2010, with Erin Keely, Chief of Endocrinology and Metabolism at The Ottawa Hospital, and the Champlain LHIN information technology team. Initial (18 month) funding for the project, to pay for specialists’ time, came from The Ottawa Hospital Academic Medical Organization alternate funding plan. E-consultations typically take 10 minutes or less of a specialists’ time and they have been paid from the initial grant.

Technical and operational support is provided by the LHIN and the Bruyère Research Institute.

National collaboration is being fostered

The Champlain LHIN initiative is one of several across the country that aim to enhance communication between primary care providers and specialists through electronic means. Since 2010 the Canadian Medical Association, has been fostering national collaboration on development of e-consultations and e-referrals.

E-consultations and e-referrals have been well integrated into the practice of medicine for many years in countries such as Holland and in US organizations such as the giant health maintenance organization Kaiser Permanente, and the Department of Veteran’s Affairs.

But those jurisdictions have, compared to Canada, a long history of using electronic medical records (EMRs) and investing heavily in information technology. In contrast, the slow spread and patchwork of EMR systems in Canada presents unique challenges.

The e-consultations are done through software — Microsoft’s Sharepoint collaboration software — that was already in use at the Champlain LHIN for sharing documents, schedules and agendas, Alexander said.  Servers are located in hospitals.  The software utiliizes standardized online forms, which were developed at the LHIN to be used for the e-consultations to provide key information. The forms also allow for additional information, such as test results and photographs, to be attached.

E-consultations are an updated version of “corridor consultations”

The usual procedure is for family doctors and specialists to “interact through the patient,” notes Keely.  E-consultations allow for more direct communication and hence the kind of relationship building between family doctors and specialists that, when family doctors had a greater presence in hospitals, used to take place in physician lounges and “corridor consultations”, she says.

Keely says that while there’s been a focus on primary care reform in the province, specialists “still do things the standard way.” Her initial interest in the project came out of frustration with the length of her waiting lists and the number of cases that she suspected could be diverted from that list.

Danielle DeBanné, a family doctor in Russell, Ont., says e-consultations have proved most useful for her “off the textbook questions, where something is a bit strange and I need advice.” These questions are often about non-urgent issues that often don’t warrant a referral; she continues to pick up the telephone for urgent referrals. However in the traditional system there are often no other means to access specialists.

If, after an e-consultation, the family physician and other specialist agrees that a referral is necessary, the patient goes into the usual queue, though not necessarily with the physician who provided the consultation. However, the e-consultation may well have streamlined the process by ensuring, for example, that the most useful tests are completed in advance of the specialist appointment and that the right doctor has been sent the referral.

Pilot expanded because of  its popularity

The Champlain pilot project was designed to test the role that e-consultations might play in improving access to specialists and was therefore to be small enough to test the service, but large enough to get meaningful data. The original plan was to involve one or two non-family physician specialties and complete 100 e-consultations, but the scope expanded when doctors heard positive reports about it and asked to participate.

The pilot was launched in April 2011 and by May 2012, when 116 primary care providers were registered, 326 consults had been completed and, in 43 per cent of cases, a referral that had been contemplated by the family doctor was avoided.

Dermatologists, endocrinologists and cardiologists were the specialists most often called upon to provide e-consultations in the pilot study. When consulting with dermatologists, family physicians often attach a photograph of the skin condition they are concerned about. Conversely, when in-person meetings between patients and specialists are essential, e-consultations are unlikely to be of benefit.

The e-consultation process prompts family doctors to state their clinical questions clearly and concisely and it can help to avoid duplication of tests, if a referral takes place, Alexander says.

In the Champlain system, family doctors typically do not identify patients by name in the e-consultation process. But the software has extremely high privacy/security settings, and if required the use of patient names for billing or other purposes would not require additional privacy settings, Alexander said.

The next phase of the project consists of further expansion in Champlain as well as up to three other LHINs; funding will be provided through the participating LHINs. Beyond that, it is expected that there will be a major expansion of e-consultation as part of a broader e-referral strategy that is currently being developed (by which time it is expected that e-consultation will also be appropriately incorporated into the OHIP fee schedule).

System can be cumbersome, but worthwhile

DeBanné and fellow family doctor Phillippe Pinard, of Renfrew Ont., are enthusiastic proponents of e-consultation, but they explain that signing on to the system can be cumbersome. It is not integrated into their respective office EMR systems, and hence requires a separate sign in process, and consultations from specialists later have to be copied and pasted back into EMRs. “It’s not quick and dirty,” says DeBanne.

But Pinard indicated that the extra time it currently takes to request a consultation in writing is often worthwhile, as he has many patients in nursing homes, for whom a trip to Ottawa to see a specialist would be difficult. “I find it is good for specific questions, or for when I am hesitating between two options, such as which medication to use.”

For e-consultations to catch on across the province, they will likely need to be embedded into family doctors’ EMRs, so that they can generate an e-consultation request just as quickly as a traditional referral letter, which most EMRs already do very quickly.  The success of growing this project from a small pilot to province-wide program is also likely dependent on the development of an appropriate reimbursement model for both family physicians and specialists.

“If we get this right,” Alexander says, e-consultations “should help reduce specialists’ wait lists.”

Moving “beyond the physical presence in medicine”

Manitoba initiated an e-referral project several years ago after first convening a meeting of family doctors and specialists to tackle wait list issues. “There was a lack of trust in the system’s ability to provide timely referrals . . . we realized we had to budget time for venting,” about the existing system, says Luis Oppenheimer, a physician who is provincial director of clinical improvement and access for Manitoba Health.

Oppenheimer, who is also medial director of Manitoba Telehealth, says the experience with e-referral has convinced him that there is a need for much more collaboration and dialogue, among physicians and with patients, that can be facilitated by going “beyond the physical presence in medicine.”

Given the success of Champlain and other e-consultation and e-referral initiatives, it appears that it is time to move from pilot projects to permanent structures and processes to allow greater and more timely consultation and referrals between primary care and specialists.