01 May eConsult Takes Canada
The e-consult Pioneers & Leaders series takes a deeper dive into the history of e-consult by targeting its birthplace—the visions and motivations of those who started it all. In a succession of interviews with healthcare innovators who pioneered or contributed to e-consult initiatives, we untangle the e-consult system’s conceptual roots and purpose, crystallize its trajectory, and map the future potential of e-consult in healthcare settings.
One fateful summer day in 2008, Ottawa-based family doctor Dr. Clare Liddy sent a referral for her patient to visit endocrinologist Dr. Erin Keely. Dr. Keely’s clinical team was already conducting triage of incoming referrals in order to ensure that patients who required appointments in a timelier manner would be seen. Despite the office’s triage system, however, Dr. Liddy was informed that the soonest available opening for her patient would be in six to nine months.
There has to be a better way, Dr. Liddy thought.
“As a family doctor I had already done a full workup and it was a complicated case which is why I was doing the referral,” Dr. Liddy said. “That was the straw that broke the camel’s back, and I said ‘okay, I have got to do something about this.’”
Bringing together their family doctor and specialist perspectives, Drs. Liddy and Keely brainstormed about issues in the health system such as long wait times and the referral process. They agreed that the crux of the discord had to do with communications between family doctors and specialists about a patient.
“Family doctors will tell you, ‘What do I worry about on a Friday night when I go home? I worry about all the people who haven’t been able to get that appointment.’” Dr. Liddy went on, “’I don’t know what going’s on with them and I’m trying to work the problem and I need to get help—do I need a face to face appointment? How long will that take?’”
If there was a way to facilitate that conversation, perhaps family doctors could obtain specialist advice sooner than the time it would take for the patient to wait for a visit. Their solution materialized into the Champlain BASETM e-consult model, which has since spread throughout Canada.
But how did they get there?
For six months, the duo revised past literature, weighing options like creating a hotline or improving on-call services. Perhaps they could launch shared care clinics, where an endocrinologist would work right out of a family doctor’s office for one day a week. Yet none of these avenues solved the issues of synchrony or extensive scheduling and coordination that curbside consults and referrals did not already present. Like Dr. Bergus from the University of Iowa, Dr. Liddy said she ultimately gravitated towards email because it was an asynchronous, convenient way to exchange information.
By June 2009, Drs. Liddy and Keely had obtained a small innovation grant from The Ottawa Hospital Academic Medical Association Innovation fund, to execute their initiative for health system improvement. It is important to note that Canada possesses a publicly funded healthcare system. Health regions are a governance model used by Canada’s provincial governments to administer and deliver public health care to all Canadian residents.
At the time of funding, email was not considered a secure enough method for patient health information exchange, so Dr. Liddy collaborated with their local government health organization, the Champlain Local Health Integrated Health Network and used Microsoft SharePoint Collaboration Space to develop the model including the e-forms. The main idea remained the same: Primary care providers could use an electronic platform to contact specialists.
“I’m a family doctor and I know a lot, I just don’t know everything,” Dr. Liddy said. “There is a lot of advice that can be transferred virtually from the specialist to me so that I can take action. Later down the road maybe the person still needs a face to face visit which is fine but at least I get the response early.”
Dr. Liddy explained a few ways in which their e-consult model, the Champlain BASETM (named after her health region), evolved to accommodate the needs of its provider users. Initially, Dr. Liddy said she and Dr. Keely had developed the service to contact endocrinologists only. But as they began to start the service, family doctors expressed trouble accessing many other specialist areas such as cardiologists, dermatologists, rheumatologists, and neurologists for their patients. Taking this into account, Dr. Liddy adjusted the service to become multi-specialty right from the start.
The service was also intended to be completely anonymous. Here, the family doctor submits their question to cardiology rather than a specific cardiologist, and the cardiologist is unaware of the family doctor’s identity. Dr. Liddy discovered from provider surveys, however, that they preferred to know the name of whom they were speaking with. At the end of the day, e-consults remain a form of social interaction. Dr. Liddy adjusted the system so providers can now log into the portal and view a directory of specialists, and specialists know to whom they are answering thus creating a virtual relationship.
This constant back and forth of feedback, trial and error throughout the first year of piloting Champlain BASETM proved formative for the program in the long run. After intensive and frequent evaluation of the e-consult service’s testing phase in the province of Ontario, Liddy said the project continued to flourish and expand. e-consult is now available 14 million people in the Ontario Province, many of whose regions are rural and can be several hours of travel away from a main referral center.
Over 14,000 primary care providers now have the option to submit clinical inquiries to 92 different specialty services offered by 750 specialist consultants throughout Ontario on behalf of the government. In the past year, 53,000 patients have had an e-consult in Ontario. These numbers continue to grow as Dr. Liddy and her team onboard new specialties and primary care providers.
“I just need what I call my Noah’s Ark,” Dr. Liddy explained. “To open up a specialty group I just need two willing experienced specialists who would like to do this, and that’s all I need to open up the equity of access for an entire population.”
Countless hours of presentations, briefing notes, lobbying and meeting with the ministry has led Dr. Liddy and her team to secure public funding for the service and receive nearly 3 million dollars for research along the way. She has been affiliated with over 70 publications about the e-consult service since its genesis. e-consult has become her main area of focus and she is the Primary Care Lead & Co-Executive Director of the e-consult Centre of Excellence.
In 2009 Dr. Liddy connected with Dr. Delphine Tout, a nephrologist at San Francisco General Hospital who had been using a similar system, called eReferral, for some years. Dr. Liddy said that Champlain BASETM has recently gained enough traction for government backing of integrating e-consult into an eReferral platform. In this way, a family doctor would submit an electronic referral to request a face to face appointment, and the system would allow for the possibility of a specialist to review the case and respond to the referral with an e-consult instead.
Dr. Liddy said some providers refuse to use e-consult because it is not integrated into an electronic medical record. In these cases, it is crucial to reaffirm the value added of e-consult for providers and patients alike.
“This [e-consult] is just another way for me to get help and support on your case so if any family doctor is feeling worried and frustrated of patients sitting on wait lists to access specialty care, then e-consult offers an alternative solution,” Dr. Liddy summarized.
Learn more about Champlain BASETM