Examination of Plastic Surgery Clinical Questions and Responses via an Electronic Consultation (eConsult) Service

Abstract

Introduction: Average wait times for plastic surgery depend on priority, but access to specialist consultation can be upwards of 1-2 years for elective referrals. The Champlain eConsult BASE™ system was developed in 2010 and is a PHIPA-compliant system that allows primary care providers to electronically send specialists questions about specific patients, potentially avoiding the need for a formal in-person consultation. Methods: Electronic Consults (eConsults) through the Champlain eConsult BASE™ system to plastic surgery from January 2021 to December 2022 were assessed by 2 reviewers. A standardized data extraction form was used, categorizing consults for question type and clinical problem. A mandatory close-out survey allowed for analysis on referring physician satisfaction, referral outcome, and impact on patient care. Results: Three hundred and thirty-one eConsults were included and were answered in an average of 2.1 ± 3.1 days. Specialists spent a mean of 14.0 ± 5.7 minutes per case. The most common content of the consults was related to hand trauma (37%), non-hand skin/soft tissue lesions (13%), and hand masses/lesions (bony or soft tissue) (8%). A formal consultation was avoided in 32%. Thirty-nine percent of cases resulted in a change in management: a referral to plastic surgery was avoided but originally contemplated by the family physician in 32%, and a referral was recommended but not originally contemplated in 7%. Conclusions: Our study demonstrates the potential of eConsults to facilitate timely consultation and avoid unnecessary formal consultations with plastic surgeons. This may reduce wait times and improve access to plastic surgeon services.

Introduction

Access to specialty care in Ontario is increasingly challenged by long wait times due to our overburdened health care system. ¹ An innovative solution has been the development of an electronic consult (eConsult) service implemented in 2010 for the approximately 1.3 million residents that make up the Ottawa region in Eastern Ontario. ² Through this PHIPA-compliant electronic web-based system, primary care providers (PCP) can asynchronously send specialists questions regarding specific patients, obviating the need for formal referral, in-person assessment, and delays in care. Lab work, investigations, and clinical images can be attached for specialist review. ²

The system allows electronic clinical questions to be received by pools of specialists, with the aim of providing responses within 7 days. Specialists have the opportunity to ask for additional information or clarification. Specialist responses may include diagnoses, guidance on management, requests for more information, or recommendations for referral for formal assessment or management. All data is stored and transmitted in an encrypted fashion according to Ontario PHIPA standards. Development of the eConsult system included consultation with the CMPA and privacy impact assessment and threat risk assessment of the service.

Specialists receive payment from the provincial health insurance at the prorated rate of $220/hour for the self-reported time spent on each eConsult. Previous studies have demonstrated significant provider satisfaction and a reduction in healthcare resource utilization for specialties such as endocrinology, orthopedic surgery, otolaryngology, and urology.^3–6

No studies to date, however, have specifically examined the eConsult patterns to plastic surgeons in the Ottawa region through this service. We hypothesize that the eConsult service continues to have a positive impact in drastically reducing the number of formal in-person referrals, improving access to care, and providing referring physicians with timely management strategies. This service may also offer the added benefit of diverting patients from urgent care and emergency departments.

Methods

Data Analysis

A retrospective review was conducted of eConsults submitted between January 2021 to December 2022 to specialists in the pool of plastic surgery, hand surgery, and pediatric plastic surgery on the Champlain eConsult BASE™ service. During this period, 4 specialists were available to respond to eConsult in one or many pools—4 in plastic surgery, 2 in hand surgery, and 2 in pediatric plastic surgery. After each eConsult, PCPs are required to complete an electronic survey, which evaluates the impact of the interaction on the patient and the PCP's decision-making process. The survey consists of 4 questions:

How the eConsult impacted the PCP's course of action.

How the eConsult impacted the PCP's decision on referring the patient.

The eConsult's educational value in guiding management of the PCP on a 5-point Likert scale.

The value of the clinical problem for upcoming continuing medical education events on a 5-point Likert scale.

PCP questions and specialist responses were assessed by 2 reviewers using a standardized data extraction form. Referrals were categorized based on question type, clinical problem, and other relevant factors. Clinical topics were classified according to the International Classification of Primary Care, 3rd Edition (ICPC-3) ⁷ and the Taxonomy of Generic Clinical Questions (TGCQ). ⁸ Question types were predefined and used for data analysis and categorization. Inter-rater reliability was tested using an 11% sample of the data.

Data Collection

All collected data were securely stored in the Champlain eConsult BASE™ system. Collected data included patient demographics (age and gender), specialist response times, time billed by specialists, the number of questions and responses, the content classification of the consults, and whether additional attachments (such as images or laboratory results) were included.

Results

In 2022, a total of 331 eConsults were submitted to plastic surgery, hand surgery, and pediatric plastic surgery specialists. The mean age of patients was 41.1 ± 23.2 years, and 57% were female. A total of 202 PCPs requested the 331 eConsults, with 92% of PCPs being physicians and the other 8% being nurse practitioners. Four specialists responded to the 331 eConsults over the 24-month study period with a mean response time of 2.1 ± 3.1 days, and 92% of cases were responded to in 7 days or less. Plastic surgeons spent a total of 14.0 ± 5.7 minutes per eConsult, leading to a mean cost of $46.77 per eConsult. Only 5% of cases required additional information or clarification by the referring provider. Table 1 provides a summary of patient and referring provider characteristics.

Table 1.

Characteristics of eConsults.

Indicator
Total number of cases	331
Patient age, years (mean ± SD)	41.1 ± 23.2
Patient sex (female), n (%)	190 (57)
Response time, days (mean ± SD)	2.1 ± 3.1
Cases responded to in 7 days or less, n (%)	307 (93)
Specialist time billed per eConsult, minutes (mean ± SD)	14.0 ± 5.7
Cost per eConsult, $	46.77
Cases not requiring clarification, n (%)	305 (92)

Of the 331 eConsults, 86 (26%) were related to hand surgery, 196 (59%) to general plastic surgery, and 49 (15%) to pediatric plastic surgery. The content of these eConsults primarily involved hand trauma (n = 121, 37%), skin/soft tissue lesions (n = 42, 13%), and hand masses/lesions (n = 28, 8%). Regarding the reported duration of the issues referred, 28% were acute (less than 4 weeks), 20% were subacute (4-12 weeks), and 17% were chronic (more than 12 weeks). The chronicity was not reported or could not be determined for 35% of the cases. Furthermore, 8% of consults included screenshots of X-ray images, and 29% included an X-ray report without images. A full breakdown of the eConsult content is provided in Figures 1 and 2.

Figure 1.

Breakdown of case content.

Figure 2.

Acuity of each case, n (%).

The responses from plastic surgeons had a significant impact on patient management (Figure 3). Almost half (49%) of the eConsults provided referring PCPs with a new or additional course of action that they would implement. In 32% of cases, formal referrals were originally contemplated but subsequently avoided based on specialist recommendation. Conversely, 7% of cases led to a referral being recommended where one had not been initially considered. In 59% of cases, management (referral or no referral) remained unchanged.

Figure 3.

Changes in management of patients. A: The impact of eConsult on primary care provider course of action. B: Impact of eConsult on the need for face-to-face referral.

Responses were rated as “valuable” or “very valuable” in 89% of cases. Additionally, in 53% of cases, PCPs agreed or strongly agreed that the case addressed an important clinical problem that should be incorporated into upcoming continuing medical education events. Full breakdown of the PCP mandatory close-out survey is shown in Figure 4.

Figure 4.

Primary care provider mandatory close-out survey results. A: 5-point Likert scale ranking if the eConsult case addressed an important clinical problem that should be incorporated into upcoming medical educational events. B: 5-point Likert scale ranking if the eConsult response was helpful or had educational value in guiding evaluation or management.

Discussion

The implementation of eConsults offers a significant opportunity to improve access to specialty care while avoiding unnecessary in-person assessments and referrals. In plastic surgery, eConsults resulted in fast response times, high referring physician satisfaction, and the prevention of unnecessary referrals in 32% of cases. This referral deflection rate is consistent with outcomes observed in other specialties.^3–6 The benefits of eConsults extend beyond simply preventing unnecessary referrals. They also increase clinic capacity, reduce wait times, and expedite access for patients who require in-person assessments. For patients, eConsults decreases the logistical burden of travelling and arranging time off work while also facilitating more accurate triage and early investigation when needed.

Additionally, 7% of eConsults to plastic surgeons led to referrals that were not initially considered by the PCP. In comparison, the average rate across the Champlain eConsult BASE™ system is 3.4%. ⁹ This demonstrates the value of eConsults in identifying the need for specialist input in cases when a referring provider might be hesitant or uncertain if a referral is warranted. Similar trends were seen in urology (8%) and orthopedic surgery (13%),^4,6 highlighting eConsult's role in ensuring patient safety and access to timely care.

Beyond improving referral efficiency, eConsults significantly impact the PCP's course of action. In 49% of cases, eConsults provided clear advice that led to the implementation of new or adjusted treatment plans, further highlighting their value in enhancing patient care without the need for specialist referral.

A major benefit of eConsults identified in our study was the speed of access to specialist response. On average, specialists responded within 2.1 ± 3.1 days, with 93% of cases receiving a response in 7 days or less. In contrast, traditional referral wait times for elective cases can extend up to 2 years, depending on priority. ¹⁰ This finding suggests that eConsults significantly reduce the time to receive specialist advice, aligning with outcomes seen in other specialties. Additionally, because eConsults are not bound by geography, they allow for broader access to specialist care. This centralized referral system is more efficient than traditional methods, where patients are often referred to a single specialist with unknown wait times.

While eConsults dramatically improve access to specialty care, there are obvious limitations in assessment and care that can be provided through an asynchronous electronic system. The main limitation of the study was that while referring physician satisfaction was high, there was a lack of follow-up and verification that patient outcomes were satisfactory and that the appropriate management plan was recommended. As such, it is unknown if patients requiring (or not requiring) formal in-person consultation was indeed correct. A recent study of eConsults in pediatrics, however, followed these patients and found no deaths or hospitalizations in cases with eConsults. ¹¹ Finally, it is also unknown, furthermore, if the population of patients without a PCP are further disadvantaged and marginalized.

Conclusion

The eConsult service has demonstrated high referring provider satisfaction, fast response times, and changes in management resulting in savings in unnecessary in-person referrals. This has broad benefits to PCPs, their patients, specialists, and the healthcare system. Future work is directed towards validation of specialist recommendations and expanding the service and utilization.