Experiences of specialist physicians with e-consultations

Abstract

An e-consultation is a form of virtual asynchronous communication between a primary care provider (PCP) and specialist physician within a shared electronic health record (EHR), designed to improve communication and timely access to specialized care. Newfoundland and Labrador (NL) initiated a province wide e-consult service in 2018 which continues today, used by PCPs and specialists working in the provincial health care system.

Objectives:

The focus of this observational study is to explore the experiences of specialists who have utilized the NL e-consult system.

Methods:

The study method was a mixed method survey. An anonymous, web-based questionnaire was sent to specialist physicians working in NL who participated in the e-consult service between January 2018 and December 2022.

Results:

Thirty-six specialists completed the e-questionnaire, with a 55% response rate (36/66). The majority were internal medicine specialists (53%), followed by surgical subspecialities (16%), psychiatrists (11%), and other (19%). Most respondents agreed there was a role for e-consults in the health care system. However, almost all respondents (90%) indicated they had no protected clinical time for completing e-consults. Moreover, 92% indicated e-consults were answered outside of regular working hours at least some of the time. About half (47%) replied they spent 1 h or less per week answering e-consults, while 30% indicated it was 2–3 h per week. Only 44% of physicians were financially reimbursed for completing e-consults.

Conclusion:

The e-consult system has been successfully introduced within the provincial health care in NL. However, issues of dedicated time for e-consults and adequate financial compensation may limit its sustainability in the long term.

Introduction

Health care delivery in Canada is under enormous strain, due in part by a shortage of primary health care providers (PCPs), as well as long wait times to access specialized care. PCPs are often the physicians who recognize a medical condition requiring specialized care, who contact or refer a patient to a specialist physician. Traditionally a referral is sent to the specialist for triage, and if accepted, the patient is placed on a waiting list to see a specialist. An e-consultation, or e-consult, is a form of virtual asynchronous communication between a PCP and specialist physician within a shared electronic health record (EHR). The purpose of these e-consults is multifactorial; PCPs can use e-consults to contact specialists for advice regarding diagnostic work-up, abnormal lab tests, or treatment options, and specialists can use the e-consult to document advice provided, reduce wait-times, and facilitate appropriate referrals.^1–3 The literature suggests that while PCPs report satisfaction with e-consults through improved clinical management skills, specialist physicians are more likely to be ambivalent.^4,5 While specialists acknowledge the potential for improved efficiency and reduction in wait time though the use of e-consults, there are outstanding issues with adequate compensation and dedicated time to complete e-consults.^1,6,7

The focus of this observational study is to explore the experiences of specialists who have utilized the e-consult system in Newfoundland and Labrador between January 2018 and December 2022 to understand its advantages and disadvantages within the Canadian health care context.

Method

To determine the attitudes and experiences of specialist physicians who had participated as consultants in the NL e-consult service, we decided the best approach was through an inquiry using an anonymous questionnaire. We thought this method would allow physicians to voice their opinions without needing to be identified. The questionnaire was developed through a review of the literature and input from physicians who were familiar with the NL e-consult service. The 27-question electronic questionnaire had a mixture of quantitative and qualitative questions, which included both multiple choice and open-ended responses. It was divided into four sections: demographics, time used on e-consults, financial compensation, and technology. The questionnaire was pilot tested for clarity and comprehension by specialist physicians who were familiar with the NL e-consult service (see Appendix A to view survey tool).

After obtaining ethics approval, we were provided with a list of specialist physicians who had participated in the NL e-consult service between January 2018 and December 2022. The names and contact emails of these physicians were provided by the Newfoundland and Labrador Center for Health Information (NLCHI), the group currently responsible for running the e-consult service. This time frame was selected as it incorporated the experiences both prior, during and post pandemic. In 2020, the NL e-consult service was integrated into the provincial electronic health record (HealtheNL).^8,9 Apart from this change, no other substantial changes have been made to the technology of the NL e-consult system, the EHR, financial compensation of physicians working in the system or work distribution.

The questionnaire was distributed by email in April of 2023, with a follow-up email reminder 2 weeks later. The link to the questionnaire was included within the email, so that physicians could directly complete the survey after clicking the link. Voluntary informed consent was obtained digitally from all participants prior to proceeding with the survey. The first electronic page of the survey included the objectives of the study and a statement that participation in the study was voluntary. Consent was requested at the end of the first page. If the physician agreed to participate in the study, consent was obtained by selecting a check box that stated “Do you consent to proceed with survey?” The question response was either “Yes, proceed to survey” or “No.” If the participant selected “Yes …,” the next page of the survey would open and they would proceed. If “No” was selected, the survey would not open. We ensured that each survey response was unique to a single email address.

The responses to the questionnaire were automatically populated into the software Qualtrics XM. No personal identifying information was collected for analysis; the names and email address of the physicians who participated in the NL e-consult service were not included in the study analysis. Microsoft Excel was used to run the descriptive statistics. Research approval was received from the Health Research Ethics Board of Newfoundland and Labrador #20231653.

Results

Thirty-six clinicians completed the e-questionnaire, with a 55% response rate (email had been sent to 66 specialist physicians). The majority of respondents were internal medicine specialists (53%), followed by surgical subspecialities (16%) and psychiatrists (11%) (and all other 19%) (see Table 1). The majority (52.8%) were salaried physicians, with the remaining (47.2%) compensated through a fee-for-service/or alternative compensation payment model.

Table 1.

Consultant physicians who participated in the NLMA E-consult system by specialty.

	N	%
Internal medicine
°Dermatology	2	6
°Endocrinology	3	8
°Geriatrics	3	8
°Hematology	5	14
°Infectious diseases	1	3
°Respirology (pulmonology)	2	6
°Rheumatology	1	3
Pediatrics	2	6
Surgery	6	16
Psychiatry	4	11
Unknown	7	19
Total	36	100%

Specialists were asked if they preferred either “face-to-face consults,” “an e-consult” or “it depends (on the clinical scenario).” The majority of respondents selected the third option (86%), with only a small minority selecting a face-to-face consult (11%), or an e-consult (3%). The opinions on e-consults varied, with one respondent stating “It is not a substitute for an in person consult but does appear to be helpful with guiding treatment and reassuring [that] current treatment is appropriate.” Another physician felt the e-consult service was overused by PCPs “… who were ordering tests they did not know the meaning of and then sending an e-consult for every value just above or just below average.” Meanwhile, one respondent indicated that their experience with e-consults was “outstanding” due to its efficiency and convenience, echoed by another provider who said “I use this service to essentially cutdown on my waitlist for those who do not need to have a dedicated appointment” (see Table 2).

Table 2.

Comments provided by specialist physicians on experiences with the NLMA E-consult system

Utility of E-consult	“I do not consider an E-consult a substitute for an in person consult. It does, however, appear to be helpful with guiding treatment and reassuring current treatment is appropriate.”
	We received a significant number of consults that were either (a) directed to the wrong specialty, (b) poorly thought out or containing inadequate details, or (c) too complex and should have been sent directly as a referral.
	Inpatient consults would be effective for quick questions, and it is often easier than trying to track someone down. Would also be helpful for rural sites to e-consult on services with questions about management.
	“Primary care (GPs and NP) were ordering tests they did not know the meaning of and then sending a e-consult for every value just above or just below average.”
	I like to take phone calls when on call and have a dialogue with the referring physician (or NP). To me the lack of discussion with e-consult or slow discussion is difficult. Typing is so time consuming as compares to speaking. When on call, and I take calls to answer patient care questions/consults - I expect to be interrupted to do this and it is an expected thing. E-consult consistently going without pause when not on call etc. was difficult. Hated the reminder emails.
	I provide this service to essentially cut down on my wait list for those who do not need a dedicated consultation appointment
Chart Review with Electronic Health Record	It should not require a chart review. That would be a formal consult. I never do a chart review. If the scope of the question would require a chart review, I suggest a formal consult. Doing a chart review outside of the context of the patient's history and physical findings, can lead to medical error.
	I have to enter a patient's chart to review, on the EHR (i.e., HealtheNL), then I need to close it and navigate back to e-consults page to enter my response.
	Very slow, difficult to look at bloodwork.
Compensation	Salaried Docs need to see this as valued, if they are doing e-consults they need to have time or some other duty relieved, not continuously be expected to do more.
	Given the current volume of patients it is becoming impossible for salaried physicians to do these while managing existing growing wait lists amongst human resource shortages.
	Volunteer Only
	It basically ended up adding unacknowledged and unremunerated workload to those of us who close to participate, it was not worth remaining as part of the e-consult service.
	On Salary and therefore not paid
	I do these out of interest and to help patients/primary care. It's not a lot of work but doesn't generate much income.
Technology	E-consults are not user friendly to the consultant.
	I have had an outstanding experience with E-consult which is a convenient and efficient system.
	Helpful to see past consults, investigations, bloodwork, etc., without navigating away from eConsult page.
	It would be helpful if there was a one time text service that notifies the provider that they received an econsult
	Yes, you need to sign into Healthenl outside of EMR to access them. There is no flagged task, it's up to you to check weekly if there are e-consults.
Follow-up/Liability	If on e-consult you made recommendations, the GP would then send you follow-up bloodwork and assume you were following the patient
	Liability issue for doctors—program needs to be improved to ensure it does not add liability on the specialist. We are providing an opinion based on the info provided by the PCP and what we can find on healthe NL. We do not accept responsibility for the patient by answering an econsult.

Time to complete e-consults

There was a substantial amount of variation to the response on how much time a specialist spent per week responding to e-consults. About half of respondents (47%) indicated they spent less than 1 h per week, about a quarter reported 1–2 h, and the remainder (30%) responded 2–3 h. Almost all respondents (90%) indicated they had no “protected clinical time” for completing e-consults. Moreover, 92% indicated e-consults were answered outside of regular working hours at least some of the time; 53% of those responded with always or most of the time. Open-ended responses on when e-consults were completed reflected the lack of protected time, such “[E-consults] often happened in found time, over lunch etc.” and “Very unfair as done after hours.”

One physician indicated that e-consults were more time consuming and less efficient compared to a phone call. “I like to take phone calls when I am on call to have a dialogue with the referring physician or NP. To me the lack of discussion with e-consult or the slow discussion is difficult. Typing is so time consuming compared with speaking. When on call, I take calls to answer patient care questions/consults. E-consults going on consistently, without pause when not on call etc. is difficult.”

Additionally, a consultant physician reported that “Timeframe for response was not reasonable,” and another “Due to it being extra work … there were delays in addressing concerns which lead to delays in care.” Other comments related to time constraints included concerns about sustainability of e-consults due to other competing priorities. “Given the current volume of (face to face) patients it is becoming impossible for salaried physicians to do these (e-consults) while managing existing growing waitlists amongst human resource shortages.”

As reflected in these comments, physicians reported a lack of dedicated time to respond to e-consults, issues with responding within the expected time frame, and expressed opinions that e-consults were extra work and not sustainable.

Use of electronic health record (EHR)

Consultant physicians were asked if they reviewed the electronic health record (i.e., chart review) to respond to an e-consult. Over two thirds (64%) of specialists indicated they reviewed the EHR either “always” or “most of the time,” while a third of indicated they “occasionally” or “never” reviewed the EHR. One physician stated that chart reviews were not required to answer e-consults “I never do a chart review. If the scope of the question would require a chart review, I suggest a formal consult.” The specialist physicians who did review the EHR were asked how much time was spent to complete this task. The majority reported taking 10 min or longer (56%), 33% spent 5–10 min, and the remaining 5 min or less.

Participants were asked about the technology of the e-consult platform. Many of the respondents (56%) agreed the platform did not pose significant technological challenges. Some specific issues included navigating between the e-consult platform and the EHR, e-consults being restricted to a hospital-monitored computer and problems with the e-notifications of e-consults. While the NLMA e-consult system is embedded in the same platform as the provincial EHR, there still existed technical challenges to allow smooth navigation between the two interfaces, as indicated by this physician comment “I have to enter a patient's chart to review, on the EHR (i.e., HealtheNL), then I need to close it and navigate back to e-consults page to enter my response.” As well, clinicians indicated there was some difficulty with notifications with e-consults, suggesting they had to self-direct to find out if there were any e-consults “There is no flagged task, it's up to you to check weekly if there are e-consults,” and “It would be helpful if there was a one-time text service that notifies the provider that they received an e-consult.”

Financial renumeration

About 81% agreed that financial compensation is important for ongoing participation in the e-consult system. Only 44% of physicians indicated that they were remunerated for completing e-consults; salaried physicians in NL are not able to bill for e-consults. Specialists physicians were especially unhappy with the lack of compensation for salaried physicians, as stated by one respondent “Salaried physicians should be compensated for e-consults. A new program cannot just be added and said to be absorbed within the normal duties of a salaried physician.”

Others suggested that e-consults did not affect the quality of referrals and were additive to their daily workload without compensation. “The quality of actual referrals did not improve [with e-consults] as it ended up adding to unacknowledged, unremunerated workload.” One responded considered e-consults “volunteer work.” Over the long term, salaried physicians completing e-consults as volunteer work is likely not sustainable.

Discussion

Our study used an anonymous electronic questionnaire to survey the experiences of specialist physicians who participated in the NL e-consult service between January 2018 and December 2022. Many consultants indicated that e-consults have a role in health care such as providing treatment suggestions or for triaging consults. While there were individual physicians who reported an outstanding experience overall, a number of challenging issues were identified, including lack of dedicated time during workhours to complete e-consults, time spent reviewing the electronic health record to find medical information, and financial renumeration. Our findings are novel in that we provide specific details on when e-consults are being completed, documenting the time spent reviewing the electronic medical record to find medical information and uncovering the specifics on how specialist physicians are reimbursed.

Time to complete e-consults

Specialists who used the NL e-consult system were asked when they completed the e-consult—92% replied outside of working hours at least some of the time. Open-ended responses indicated that they were completed in “found time”—over lunch, between tasks, and after hours. Within our clinician group, about half (47%) replied they spent 1 h or less per week responding to e-consults, 25% 1–2 h weekly, while 30% indicated it was closer to 2–3 h per week. These results indicate that consultants are spending 1–3 h per week answering e-consults—outside of working hours.

Time spent responding to e-consults was compared to a (traditional) telephone appointment by a respondent, implying that the phone consultations were quicker compared to e-consults. This physician also pointed out that a phone call allows the consultation to be completed within the same interaction, while the e-consultation can continue on for days, even after the consultant has completed the call shift. Although we recognize that the NL e-consult system allows for the consultant to control their availability (i.e., posting “away or unavailable dates”) there is some inevitable follow-up that could occur during the time the consultant is not available or has requested they not answer e-consults. Therefore, the time spent answering e-consults is likely dependent on the number of back-and-forth communications between specialist and PCP, which may expand the time to answer an e-consult longer than what is reported. A systematic review completed by the JAMA Network (2024) reviewed articles that explored e-consult experiences which found the time responding to e-consults ranged from 14 to 78 min. ¹⁰

Another issue that the consultant physicians reported was in reference to the turn-around time for answering e-consults. One of the most often touted benefits of e-consults is the quick response from a consultant. The NL e-consult system, according to the NLMA website, boasts that using the e-consult system “can enhance the relationship between the PCP and patient due to the timely response—less than seven days.” ⁹ However, the consultant physicians reported that this time frame set unrealistic expectations and that the turnaround time could lead to delay of care. The rapid turn-around-time seems to have put an additional time pressure on consultants that did not exist prior to e-consults.

The responses from the specialist physicians indicate that they did not experience a reduction in the current referral volume or reduction on number of face-to-face appointments. One physician lamented that e-consults management was becoming unstainable. Furthermore, a consultant indicated that the e-consult system was additive to their current workload.

The ability to incorporate e-consults into the specialist workday has been flagged as a concern in a number of previous studies. Bhanot et al. (2021) sought feedback from health care providers who used e-consults at a large academic hospital, who reported it took “too much time to complete an e-consult” and that there was an “increase in workload.” ¹¹ Rodiguez et al. (2015) asked specialists who participated in e-consults to rate whether time was saved; these physicians gave a rating of 3 on a 5-point scale (N = 4), stating that e-consults do not save time for health care providers or patients, and sometimes created additional workload. ² A study on six gastroenterologists who completed e-consults cited “a busy workload” as the main barrier for providing timely e-consults. ¹ Keely et al. surveyed specialists perspectives on the Ontario e-consult system found some specialists wishing for more cases and others worried that more cases could pose a challenge, stating “protected time to do this (e-consult) … should not be on top of regular work.” ³ These studies have suggested that e-consults may contribute to an increase in the workload of consultant physicians, on top of their regular workload. Our study indicates this is likely true, given the increased time for electronic documentation compared to consultation completed over the phone (as talking takes less time than writing), the time pressures created by responding to e-consults in the specified time frame (in this case one week), and the potential for e-consults to be completed over days with back and forth responses, including outside of time the consultant is not available. In addition, many physicians stated explicitly that it was “additional work”—in some cases unpaid work as salaried physicians were not compensated, not to mention being done outside of working hours.

Use of the electronic health record (EHR)

The fact that the NL e-consult system is embedded into the provincial EHR would suggest that the time to complete e-consults should be highly efficient and streamlined. However, of the 2/3 of physicians who used the EHR to respond to e-consults (a small minority indicated they never use the EHR), 90% reported 5 min or more to review the medical record. The specific problems with searching the electronic medical record to respond to an e-consult included the time spent navigating between platforms, while others reported that the system was slow and cumbersome, making it difficult to find the necessary medical information. The issue of reviewing the EHR has been found in the literature, for example, as stated by a physician in the Bhanot study, “(It) Does take time to review the EHR.” ¹¹ Furthermore, the study of GI physicians who used e-consults reported they generally spent more that 15 min per e-consult, and reported “despite the shared EMR, identifying the relevant information from accumulated notes and test results can be challenging.” ¹ A study on radiologists using e-consults within the EHR suggested there is a potential to integrate information from the EHR which could consolidate all patient data and management suggestions in one location. However, the same study acknowledged that time spent responding to e-consults by radiologists was considered “noninterpretive time” which could be perceived as a decrease in productivity. ¹² Certainly, the time spent answering e-consults can vary considerably, depending on the ease of finding relevant information within the EHR, and how well the EHR interfaces with the e-consult system. The use of EHR for completing e-consults requires further exploration if the e-consult system is to be effective and efficient.

Financial remuneration

One of the other major issues identified by this group was financial remuneration. Firstly, only fee-for-service physicians could bill for e-consults, and salaried physicians were not compensated for their time. As stated by one physician, it was “volunteer.” The issue of adequate re-imbursement is a common theme in the literature; Bhanot et al. found within a group of physicians who used e-consults, several were frustrated that they were not compensated for their time, and that billing codes were much lower than the actual time spent performing the consult. ¹¹ Similarly, none of the six surveyed GI specialists who took part in a pilot program for e-consults agreed that the reimbursement for this activity was adequate for the time spent (reported as 15–30 + min per e-consult). ¹ While Brenton et al. acknowledged that negotiating provider renumeration in e-consults was an important strategy for scaling-up this technology, the paper indicated that fee-for-service codes for specialists was approved for Newfoundland and Labrador in 2019. ¹³ Unfortunately, this important strategy omitted the salaried physicians, who did not have an avenue for reimbursement of their time or expertise for providing this virtual consultation.

Future directions

Feedback from of both PCPs and specialist physicians on their experiences with e-consults is vital to the sustainability of this technology. We suggest replicating this study in other provinces who have implemented e-consults to determine whether the challenges are similar. It would be prudent to examine total weekly/annual volume of e-consults in comparison to the face-to-face consults to determine if e-consults reduce the workload, or if they generate additional work for specialists. It would be of interest to explore the potential use of e-consults beyond the triaging/virtual consult, such as providing in-hospital consultations between specialists.

Limitations

Our study had several limitations. As salaried physicians were not financially compensated for e-consults, there may have been an (un)conscious negative bias toward e-consults from these respondents. Secondly, as our sample size and response rate were modest, the views expressed may not reflect the experiences of other consultant physicians who did not complete the questionnaire. As well, given the small sample size and the inability to parse findings by specialty, the diversity of specialists responding to the survey may have impacted the results as different specialties use the e-consults differently. Finally, given that the results are from a small academic center, these findings may not be generalizable to larger academic centers with a larger pool of specialist physicians available to complete e-consults.

Conclusions

E-consultations are finding a place within the Canadian medical health care system. While a promising avenue to provide PCPs with medical advice and improving access to specialized care, there are some obstacles that should be addressed order for this tool to become integrated into the health care workforce nationally. If the e-consult system to be maintained and/or expanded at least in Newfoundland and Labrador, issues of incorporating the e-consults into the specialists’ workday, adequate and fair financial compensation, and facilitation of the EHR to complete chart reviews need to be addressed.