Abstract
Background
Limited access to specialty care contributes to emergency department (ED) crowding in Canada. Virtual provider-to-provider consultation platforms may support primary care management and reduce unnecessary ED utilization. The purpose of this study was to assess primary care providers’ perceptions of whether virtual peer-to-peer consultations prevented ED visits.
Methods
We conducted a cross-sectional analysis of post-consultation surveys completed by clinicians using the Virtual Hallway platform, an electronic consultation system enabling synchronous specialist advice to primary care providers, in Nova Scotia, Canada. Providers reported whether the consultation helped manage the patient’s condition and whether it potentially prevented an ED visit. Urgency of avoided escalation was also recorded. Descriptive analyses examined responses by provider type, specialty, and geographic zone.
Results
Among 587 respondents, 29.1% believed the consultation prevented an ED visit, 51.6% did not, and 19.3% were unsure. Perceived ED avoidance was higher in rural zones (35.0%) than in the urban Central Zone (22.4%). Among avoided visits, 9.9% were classified as highly urgent, 53.2% moderately urgent, and 36.8% not urgent. Nearly all respondents (96.3%) reported improved patient management.
Conclusions
Virtual peer-to-peer consultation was perceived to prevent ED visits in nearly one-third of cases, with greater impact in rural settings. These findings suggest potential system-level benefits in reducing avoidable emergency care utilization.
Keywords
Introduction
Access to specialty care remains a major challenge in Canada, with wide-ranging implications for patients, providers, and the health system. Canadian patients report some of the longest wait times for specialist appointments internationally, often extending to months for routine referrals. 1 These delays contribute not only to unmet clinical needs but also to inefficient use of acute care resources, as patients turn to emergency departments (EDs) for conditions that could otherwise be managed in outpatient specialty settings. 2 The shortage of specialists—particularly in psychiatry, internal medicine, and pediatrics—further amplifies this problem, with barriers to access disproportionately affecting rural populations and socially marginalized groups.
Emergency department overcrowding is a critical and persistent issue in Canada, associated with adverse outcomes including prolonged wait times, increased hospital admissions, unsafe discharges, and higher rates of patients leaving without being seen.3,4 National data highlight median times to physician initial assessment exceeding one hour, median lengths of stay of over three hours for discharged patients, and more than ten hours for admitted patients. 5 Overcrowding imposes not only clinical risks—such as delays in timely care and increased medicolegal exposure—but also financial and operational burdens on hospitals, including lost revenue from ambulance diversions and diminished staff engagement. 6 Despite targeted reforms, overcrowding remains especially severe in high-volume urban centres and is recognized as a systemic threat to patient safety and care quality.5,7
One underrecognized driver of ED use is the lack of timely access to specialist input. Patients whose conditions worsen while awaiting outpatient specialty care often present to the ED for management, while primary care providers (PCPs) may direct patients to emergency services when diagnostic uncertainty or perceived risk exceeds their scope in the absence of specialist advice. In rural settings, limited on-site specialty coverage compounds this dynamic, leading to preventable ED presentations or interfacility transfers. 8 The American Academy of Pediatrics has emphasized that when subspecialty care is inaccessible, the ED becomes the default site for complex patient management, further exacerbating crowding and inefficiency. 6
Virtual provider-to-provider consultation platforms have emerged as a strategy to bridge this access gap. Prior studies have demonstrated that synchronous peer-to-peer consultation enables PCPs to manage patients without formal referral in the majority of cases, with more than 80% of consults avoiding a specialist referral.9,10 While referral avoidance is an important efficiency outcome, less is known about the potential for such consultations to prevent ED visits. Given the high costs, operational strain, and clinical risks associated with ED overcrowding in Canada, understanding whether provider-to-provider consultation can mitigate unnecessary ED utilization is a critical next step.
The objective of the present study was to address this gap by examining primary care providers’ perceptions of whether virtual peer-to-peer consultations prevented an ED visit. In doing so, it extends existing evidence on referral avoidance to the ED context, with implications for both clinical practice and health system policy.
Methods
Study Design and Setting
We conducted a cross-sectional descriptive study using post-consultation survey data collected from users of Virtual Hallway, a provider-to-provider electronic consultation platform implemented in Nova Scotia, Canada. Virtual Hallway enables primary care providers (PCPs) and other clinicians to obtain synchronous specialist advice across a wide range of disciplines. The platform is accessible to family physicians, nurse practitioners, and select specialists practicing in both urban and rural health zones. Survey data were collected between December 5th, 2024 and July 2nd, 2025. Virtual Hallway had already been implemented across Nova Scotia prior to the study period, and thus the data represent established, real-world use of the platform rather than initial rollout or pilot-phase activity.
Participants
Eligible participants included a convenience sample of all clinicians who submitted a consultation through Virtual Hallway and completed the post-consultation survey during the study period. The study included all available survey responses. Responses were analyzed at the level of individual consultations; therefore, clinicians could contribute multiple survey responses if they submitted more than one consult during the study period. As such, responses were not independent at the provider level, and clustering by clinician was not separately analyzed in the descriptive analysis. Submitting the post-consultation survey was optional for the providers. A total of 2425 consultations were eligible for this study period, of which 587 surveys were submitted (response rate: 24.2%). Respondents represented multiple provider types, including family physicians, nurse practitioners, and specialists. Consultations spanned a broad range of medical and surgical specialties. Surveys with incomplete responses to the ED avoidance question were excluded from the primary analysis; no secondary analyses were conducted including these incomplete responses. By proceeding with the survey, participants acknowledged their consent to engage in the study. To protect participant privacy, no personally identifiable information was collected. This study received a research ethics board exemption letter from the Nova Scotia Health Research Ethics Board (REB FILE #: 1032440). It met the requirements outlined in the Tri-Council Policy Statement Chapter 2. Informed consent was deemed unnecessary, as the study involved the use of secondary anonymous data.
Data Collection
Upon closure of each consult, referring providers were invited to complete a standardized electronic survey embedded within the platform however completion of each survey was optional and could be closed without completing the survey. The survey instrument was developed internally as part of routine program evaluation and was informed by prior Virtual Hallway evaluations and standard quality improvement metrics; it has not undergone formal external validation. The survey captured: 1) Perceived clinical utility of the consult (“Did the advice help you manage the condition more effectively?”), 2) Perceived ED avoidance (“Do you believe this consult potentially prevented an ED visit?”) with response options: Yes, No, Unsure, 3) Urgency of avoided escalation (for respondents answering “Yes”), categorized as: Highly urgent, Moderately urgent, Not urgent.
Additional variables extracted included referring provider type, consulted specialty, and geographic health zone within Nova Scotia (Central, Eastern, Northern, Western, IWK Health Centre). Health zones were subsequently grouped into urban (Central Zone and IWK Health Centre) and rural (Eastern, Northern, Western) categories for comparative analyses.
Outcomes
The primary outcome was provider-perceived ED avoidance, defined as a “Yes” response to the survey question regarding whether the consult prevented an ED visit. Secondary outcomes included perceived urgency of avoided escalation, stratified by provider type, specialty, and geographic zone.
Statistical Analysis
We performed descriptive analyses to summarize response frequencies and proportions for all survey items. Categorical variables were reported as counts and percentages. Cross-tabulations were conducted to examine perceived ED avoidance by: Referring provider type, Consulting specialty, Health zone.
Urgency categories were analyzed among respondents who indicated ED avoidance. Specialty-level analyses focused on the five most frequently consulted specialties, with full distributions presented in appendices. Urban–rural comparisons were conducted by grouping Eastern, Northern, and Western zones. Due to the exploratory nature of the study and small cell sizes in several categories, inferential statistical testing was not performed.
All analyses were conducted using Microsoft Excel (Microsoft Corporation, Redmond, WA). Respondents with missing data for a given variable were excluded from the corresponding subgroup analysis.
Results
Characteristics of Participants and Consultations (n = 587)
Cells with counts fewer than 5 have been suppressed to preserve confidentiality.
Overall Perceived ED Avoidance
Overall ED Avoidance Summary
Among the 171 cases perceived to have avoided an ED visit, most were judged to be of moderate urgency (91, 53.2%), followed by not urgent (63, 36.8%), and highly urgent (17, 9.9%). This distribution suggests that while many perceived ED avoidances related to conditions of moderate severity, a meaningful proportion involved situations deemed highly urgent.
Perceived ED Avoidance by Referring Provider Type
Urgency of Perceived ED Avoidance by Referring Provider Type (Among ‘Yes’ Responses)
Cells with counts fewer than 5 have been suppressed to preserve confidentiality.
Perceived ED Avoidance by Specialty
ED Avoidance by Specialties Type (Top 5 Specialty, Full List in Appendix 1)
Cells with counts fewer than 5 have been suppressed to preserve confidentiality.
Dermatology, psychiatry, and rheumatology demonstrated contrasting urgency profiles: dermatology showed the highest proportion of highly urgent cases, psychiatry leaned toward moderate urgency, and rheumatology largely involved conditions considered not urgent.
Distribution of Referrals Across Specialties
Cross-Tabulation (Provider × Specialist) for Top 5 Specialties (Full List Available in Appendices)
Cells with counts fewer than 5 have been suppressed to preserve confidentiality.
Perceived ED Avoidance by Health Zone
Analysis by health zone revealed notable geographic variation (Appendix 3). In the Central Zone (urban), 22.4% of consults were judged to have prevented an ED visit. In contrast, the combined Eastern, Northern, and Western Zones (rural) reported a higher rate of 35% perceived avoidance. Individually, the Western Zone showed the highest perceived ED avoidance (39.1%), followed by Northern (35.0%) and Eastern (30.8%). The IWK Health Centre (urban pediatric tertiary care centre) reported no ED avoidances, though only three responses were recorded. As a specialized pediatric centre, the IWK may not be directly comparable to other urban settings. Geographic health zone data were missing for 213 of 587 respondents (36.3%). As a result, these findings should be interpreted with caution, particularly if missingness is not random. Detailed counts and proportions by health zone are presented in Appendix 3.
Discussion
This study examined primary care providers’ perceptions of whether virtual peer-to-peer consultations prevented ED visits. Approximately 29% of consults were judged to have avoided an ED visit, with higher rates in rural zones compared to urban. These findings underscore the role of interprofessional consultation in supporting primary care management and potentially reducing avoidable ED utilization.
Comparison With Prior Literature
Our observed rate of perceived ED avoidance is more modest than rates of overall visit avoidance reported in the e-consult literature, where between 60% and 90% of cases are managed without escalation to in-person clinics or emergency care.11,12 It is important to note that most prior studies combine avoided specialty visits with avoided ED presentations. In contrast, our outcome measure was restricted to ED avoidance as perceived by the referring provider, representing a narrower and more conservative construct relative to broader “any visit avoided” measures. However, as a perception-based and optional survey outcome, these estimates may still be subject to upward bias due to response bias and social desirability.
Virtual Hallway itself has previously been shown to facilitate avoidance of in-person referrals, with 84% of consults not requiring subsequent specialist referral.9,10 Taken together with the present findings, this suggests that while referral avoidance is the dominant outcome, a substantial minority of cases are also perceived to prevent ED visits. This distinction highlights the multifaceted system benefits of peer-to-peer consultation.
Specialty-level variation in our data is consistent with the literature. Dermatology and psychiatry were prominent in perceived ED avoidance, reflecting evidence that these specialties often benefit from rapid access to remote advice.11,12 Dermatology consults frequently involved conditions judged highly urgent, consistent with the potential of timely dermatologic input to triage acute presentations such as severe rashes or infections. Psychiatry consults, by contrast, were more often of moderate urgency, aligning with studies showing that psychiatric consultation helps PCPs manage patients without escalation to acute services. 13 Rheumatology consults were most often considered not urgent, suggesting that benefits in this area may accrue more to efficiency and patient flow than to direct ED avoidance.
Geographic variation was also notable: providers in rural zones perceived ED avoidance more frequently than those in the urban Central Zone. This is consistent with evidence that rural populations have higher rates of preventable and lower-acuity ED visits, often due to limited access to timely primary and specialty care.8,14 Telehealth-enabled provider-to-provider consultation has been shown to reduce unnecessary transfers, improve local management, and support decision-making in rural environments.15,16 Our findings suggest that virtual peer-to-peer platforms may deliver disproportionate value in rural contexts, where clinical uncertainty and system constraints elevate the risk of unnecessary ED use.
The results of this study contribute to the growing body of evidence that peer-to-peer consultation supports more efficient care pathways. Although only one in three consults was perceived to prevent an ED visit, such cases may be associated with meaningful system efficiencies and improved patient experiences. When considered alongside the high rate of referral avoidance demonstrated in prior Virtual Hallway studies, the findings highlight complementary outcomes that together may reduce pressure on both specialty services and emergency departments. These findings add to prior evidence of referral avoidance and reinforce the potential of such platforms to improve access, optimize resource use, and alleviate strain on emergency services. Policymakers may consider investment in and reimbursement for provider-to-provider consultation services through publicly funded billing codes as a scalable strategy to improve system efficiency and address geographic disparities in access to care.
Limitations
Several limitations must be acknowledged. First, the outcome measure reflects provider perception rather than observed utilization; providers may overestimate the likelihood of ED avoidance due to social desirability or attribution bias, which would inflate the observed rate. Second, the voluntary nature of survey completion may introduce response bias if clinicians who found the consultation more useful were more likely to respond, again potentially biasing results upward. Third, specialty-specific analyses were limited by small cell sizes, particularly in less frequently consulted areas. Fourth, contextual factors such as local urgent care availability may confound the urban–rural comparisons and the inclusion of the IWK Health Centre—a specialized pediatric tertiary care setting—within the urban grouping may not be directly comparable to other urban zones. Fifth, geographic health zone data were missing for approximately one-third of respondents, which may limit the generalizability of zone-level findings. If missingness is not random, the direction and magnitude of the observed rural–urban differences may be biased and could shift. In addition, clinicians can submit multiple consults which introduces clustering that can distort subgroup distributions and any implied comparisons. Finally, as with much of the literature, the observational design precludes causal inference.
Conclusion
Virtual peer-to-peer consultation was perceived to prevent ED visits in nearly one-third of cases, with higher impact in rural settings and notable specialty variation.
Supplemental Material
Supplemental Material - Perceived Emergency Department Avoidance Following Virtual Provider-to-Provider Consultation: A Cross-Sectional Study
Supplemental Material for Perceived Emergency Department Avoidance Following Virtual Provider-to-Provider Consultation: A Cross-Sectional Study by Daniel Rasic, Ashfaq Adib, and Jacob Cookey in Journal of Primary Care & Community Health.
Footnotes
Acknowledgments
The authors would like to acknowledge Nova Scotia Health and the IWK Health Centre for their support, as well as the participating clinicians for their valuable contributions to this research.
Ethical Considerations
This study received a research ethics board exemption letter from the Nova Scotia Health Research Ethics Board (REB FILE #: 1032440). It met the requirements outlined in the Tri-Council Policy Statement Chapter 2.
Consent for Publication
Informed consent was deemed unnecessary, as the study involved the use of secondary anonymous data.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article: There was no material support beyond the standard resources of the authors’ respective affiliations.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors (DR, AA, and JC) are affiliated with Virtual Hallway, the company that provides the provider-to-provider consultation platform evaluated in this study. No other potential conflicts of interest are known.
Data Availability Statement
Data available upon reasonable request.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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