Building Capacity for Specialized Services Through eConsultation

Research Question: What is the impact of an electronic consultation (eConsult) service on referral rates from primary care doctors to specialists?

The objective of this study is to assess the impact of eConsult service on referral rates using a randomized controlled trial (RCT) of eConsult versus usual referral practices. We hypothesized that access to eConsult would lead to a decrease in referral requests for face-to-face specialist visits from primary care providers in the intervention group.

Trial Design: This study is a parallel arm RCT that recruited family physicians in Ontario to use the Champlain BASE™ eConsult service. Physicians will be randomized 1:1 to either the intervention or control arm between January 31, 2014 and September 26, 2014. Although originally intended as a stepped wedge RCT, the design was changed to a parallel arm before and after RCT due to the fact that randomization could not be performed at a discrete time point for all participants.

Intervention: In 2009 our team began developing, implementing, and evaluating an innovative eHealth solution called the Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service. eConsult is a form of asynchronous communication whereby primary care providers (PCP) and specialists can communicate directly about a patient through a secure web-based application. Specifically, PCPs can submit a patient question (usually for a patient who would otherwise have been referred) to a specialty service via a web-based portal. They can attach any additional information (e.g. photos, test results, Electronic Medical Record-generated letter). The case is assigned to a specialist, who receives an email notification prompting them to access the case via the secure site. Specialists are expected to provide an answer within one week. They can reply to the question, request additional information, or recommend a referral, and advise the PCP on other matters such as medication changes, additional tests, or other critical actions to be completed before the face-to-face specialty care appointment. PCPs ultimately decide how to apply the specialist's suggestion and when the case can be closed. Specialists are compensated on a pro-rated hourly basis. The communication between PCPs and specialists is iterative and the discussion can occur back and forth until, ultimately, the PCP closes the case. After undergoing registration, which included orientation and brief training on the use of the service, physicians randomized to the intervention group will receive access to eConsult right away (pending completion of an orientation session), while those randomized to the control group will use standard referral practices for one year after randomization and then will receive an option to use eConsult in the second year. The intervention period for the treatment group therefore will last one year following the enrollment/randomization period.The pre-randomization period will be 12 months in duration for both groups.

Sample size: With 50 physicians in each arm, assuming an average of 800 patients per physician for a total of 80,000 patients seen, the investigators will achieve 80% power to detect an absolute reduction in referrals of 6 per 100 patients from a control arm referral rate of 31 per 100 patients, estimated from a previous study, using a two-sided significance level of 5% and assuming a between-provider coefficient of variation of 0.38.