A Systematic Review of Asynchronous, Provider-to-Provider, Electronic Consultation Services to Improve Access to Specialty Care Available Worldwide

May combine two claims.

Many eConsult services were primarily limited to single specialty services, particularly dermatology, so generalizability of impact across other specialty areas was not established.

“It was additionally shown that many eConsult services were primarily limited to single specialty services, particularly dermatology, thus generalizability of impact across other specialty areas was not established.”

• cites [5] 5. Liddy C, Drosinis P, Keely E. Electronic consultation systems: Worldwide prevalence and their impact on patient care-A systematic review. Fam Pract 2016;33:274-285. sourceNot checked — no full text of the source
• cites [6] 6. Vimalananda VG, Gupte G, Seraj SM, Orlander J, Berlowitz D, Fincke BG, et al. Electronic consultations (e-consults) to improve access to specialty care: A systematic review and narrative synthesis. J Telemed Telecare 2015;21:323-330. sourceDisputed

  The Results (Study characteristics; page unavailable) say that the three sites accounting for most reviewed articles offered multiple specialties; only five of 27 articles described single-specialty programs. The Methods (Eligibility criteria; page unavailable) say image-based dermatology consultations were excluded. The Discussion (Limitations; page unavailable) limits generalizability because studies were concentrated in three health systems, not because most services were dermatology-only. (LLM, conf=0.88)

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

Previous reviews of eConsult demonstrated its overall feasibility in application.

“Previous reviews evaluating Consult's use and impact demonstrated its overall feasibility in application and its ability to improve timely access to specialty care.5,6”

• cites [5] 5. Liddy C, Drosinis P, Keely E. Electronic consultation systems: Worldwide prevalence and their impact on patient care-A systematic review. Fam Pract 2016;33:274-285. sourceNot checked — no full text of the source
• cites [6] 6. Vimalananda VG, Gupte G, Seraj SM, Orlander J, Berlowitz D, Fincke BG, et al. Electronic consultations (e-consults) to improve access to specialty care: A systematic review and narrative synthesis. J Telemed Telecare 2015;21:323-330. sourceSupported

Classified as probably not a substantial claim.

The Quadruple Aim Framework proposes that optimizing health system performance should involve simultaneously pursuing four interdependent objectives: population health, patient experience, provider experience, and per capita costs.

“This framework proposes that the optimization of the performance of the health system should involve simultaneously pursuing four interdependent objectives: population health, experience of receiving care (patients), experience of providing care (providers), and per capita costs.”

• cites [7] 7. Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Medicine 2014;12:573-576. sourceSupported

May combine two claims.

Other eConsult services are independent of individual health records and use secure web-based portals to link providers, such as Champlain BASE, TNMG, and KSYOS, or harness secure intranet e-mail such as AKO.

“Other eConsult services are independent of individual health records and use a secure web-based portals to link providers, such as the Champlain BASE in Canada, [20][21][22][23][24][25][26][27][28][29][30][31][32] TNMG in Brazil, [33][34][35][36] and KSYOS in The Netherlands, 37 or harness secure intranet e-mail as the means of communication, such as Army Knowledge Online (AKO).38”

• cites [20] 20. Fogel A, Khamisa K, Afkham A, Liddy C, Keely E. Ask the eConsultant: Improving access to haematology expertise using an asynchronous eConsult system. J Telemed Telecare 2016;23:421-427. sourceNot checked — no full text of the source
• cites [21] 21. Liddy C, Afkham A, Drosinis P, Joschko J, Keely E. Impact and satisfaction with a new eConsult service: A mixed methods study of primary care providers. J Am Board Fam Med 2015;28:394-403. sourceSupported
• cites [22] 22. Liddy C, Deri Armstrong C, Drosinis P, Mito-Yobo F, Afkham A, Keely E. What are the costs of improving access to specialists through eConsultation? The Champlain BASE experience. Stud Health Technol Inform 2015;209:75-83. sourceNot checked — no full text of the source
• cites [23] 23. Liddy C, Drosinis P, Deri Armstrong C, McKellips F, Afkham A, Keely E. What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluation. BMJ Open 2016; 6:e010920. sourcePartly supported

  Methods > The eConsult service (page not provided) identifies Champlain BASE as a service in Canada and says primary care providers use a secure web-based platform to contact specialists. It does not say whether the platform is independent of individual health records. This source is cited for Champlain BASE, not for the separately cited services. (LLM, conf=0.84)

  Experimental — accuracy not yet measured
• cites [24] 24. Liddy C, Drosinis P, Joschko J, Keely E. Improving access to specialist care for an aging population. Gerontol Geriatr Med 2016;2:1-7. sourcePartly supported

  The Introduction identifies Champlain BASE as an eConsult service launched in Ottawa, Canada, and Method > The eConsult Service describes its secure web-based platform linking primary care providers with specialists. Our copy does not establish that the platform is independent of individual health records. The citations following TNMG, KSYOS, and AKO attach those examples to other sources, not this paper. (LLM, conf=0.84)

  Experimental — accuracy not yet measured
• cites [25] 25. Johnston DL, Murto K, Kurzawa J, Liddy C, Keely E, Lai L. Use of electronic consultation system to improve access to care in pediatric hematology/ oncology. J Pediatr Hematol Oncol 2017;39:e367-e369. sourceNot checked — no full text of the source
• cites [26] 26. Tran C, Liddy C, Pinto N, Keely E. Impact of question content on e-consultation outcomes. Telemed J E Health 2016;22:216-222. sourceNot checked — no full text of the source
• cites [27] 27. Murthy R, Rose G, Liddy C, Afkham A, Keely E. eConsultations to infectious disease specialists: Questions asked and impact on primary care providers' behavior. Open Forum Infect Dis 2017;4:0fx030. sourcePartly supported

  The Methods section (page not provided) describes Champlain BASE in Canada as a secure web-based service through which primary care providers send questions to specialists. Our copy does not say that it is independent of individual health records. This citation is attached to Champlain BASE, not to the separately cited TNMG, KSYOS, or AKO examples. (LLM, conf=0.84)

  Experimental — accuracy not yet measured
• cites [28] 28. Shehata F, Posner G, Afkham A, Liddy C, Keely E. Evaluation of an electronic consultation service in obstetrics and gynecology in Ontario. Obstetr Gynecol 2016;127:1033-1038. sourceNot checked — no full text of the source
• cites [29] 29. Liddy C, Smyth C, Poulin PA, Joschko J, Rebelo M, Keely E. Improving access to chronic pain services through econsultation: A cross-sectional study of the Champlain BASE eConsult Service. Pain Med 2016;17:1049-1057. sourceNot checked — no full text of the source

May combine two claims.

In Brazil, specialists described the referral process as unorganized, lacking patient triaging, and consisting of inadequate communication between providers.

“In Brazil, specialists described the referral process as unorganized, lacking patient triaging, and consisting of inadequate communication between providers.4”

• cites [4] 4. Juliani C, MacPhee M, Spiri W. Brazilian specialists perspectives on the patient referral process. Healthcare (Basel) 2017;5:4. sourceSupported

May combine two claims.

In other studies, when asked about satisfaction with eConsult, 75-100% of providers reported being satisfied, and most providers reported that they would use eConsult again in the future.

“In other studies, when asked about satisfaction with eConsult, 75-100% of providers reported being satisfied, 33,47 and most providers reported that they would use eConsult again in the future.13”

• cites [33] 33. Marcolino M, Minelli Figueira R, Pereira Afonso dos Santos J, Silva Cardoso C, Luiz Ribeiro A, Alkmim MB. The experience of a sustainable large scale Brazilian telehealth network. Telemed J E Health 2016;22:899-908. sourceNot checked — no full text of the source
• cites [47] 47. Segura BT, Bustabad S. A new form of communication between rheumatology and primary care: The virtual consultation. Reumatol Clin 2016;12:11-14. sourceNot checked — no full text of the source
• cites [13] 13. Rodriguez KL, Burkitt KH, Bayliss NK, Skoko JE, Switzer GE, Zickmund SL, et al. Veteran, primary care provider, and specialist satisfaction with electronic consultation. JMIR Med Inform 2015;3:e5. sourceSupported

May combine two claims.

Patients identified communication as the domain most important regarding their overall satisfaction with the eConsult process and unanimously indicated they intended to use eConsults in the future based on quality and timeliness of care.

“Furthermore, patients identified communication (effective communication with PCPs or providers) as the domain that was most important regarding their overall satisfaction with the eConsult process and unanimously indicated that they intended to use eConsults in the future based on the quality of care and the timeliness of care.13”

• cites [13] 13. Rodriguez KL, Burkitt KH, Bayliss NK, Skoko JE, Switzer GE, Zickmund SL, et al. Veteran, primary care provider, and specialist satisfaction with electronic consultation. JMIR Med Inform 2015;3:e5. sourceSupported

May combine two claims.

In a randomized controlled trial of cardiology eConsults, patients who had an eConsult were significantly more likely (1.5 times) to receive a consultation with a cardiologist and had lower rates of emergency department utilization than those who had traditional face-to-face consultations.

“The results showed that those who had an eConsult were significantly more likely (1.5 times) to receive a consultation with a cardiologist and had lower rates of emergency department utilization than those who had traditional face-toface consultations.39”

• cites [39] 39. Olayiwola JN, Anderson D, Jepeal N, Aseltine R, Pickett C, Yan J, et al. Electronic consultations to improve the primary care-specialty care interface for cardiology in the medically underserved: A cluster-randomized controlled trial. Ann Fam Med 2016;14:133-140. sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

May combine two claims.

Patients rated the service high (median ratings of 4) for quality of care, timeliness, improved access, and safety.

“They also rated the service high (median ratings of 4) for quality of care, timeliness, improved access, and safety.”

• cites [13] 13. Rodriguez KL, Burkitt KH, Bayliss NK, Skoko JE, Switzer GE, Zickmund SL, et al. Veteran, primary care provider, and specialist satisfaction with electronic consultation. JMIR Med Inform 2015;3:e5. sourceSupported

May combine two claims.

Another study estimated monthly savings for the military by using eConsult to be $140,907 (yearly savings $467,181), where civilian monthly savings were estimated as $28,260 (yearly savings $105,400).

“Alternatively, another study estimated monthly savings for the military (using a cost minimization analysis) by using eConsult to be $140,907 (yearly savings were $467,181); where civilian monthly savings were estimated as $28,260 (yearly savings were $105,400).46”

• cites [46] 46. Lin AH, Cole JH, Chin JC, Mahnke CB. The Health Experts onLine at Portsmouth (HELP) system: One-year review of adult and Pediatric Asynchronous Telehealth Consultations. SAGE Open Med 2016;4: 2050312115626433. sourcePartly supported

  The Results report projected monthly savings of $140,907 from prevented medical evacuations and $28,260 from prevented civilian referrals, based on regression of the first-year data. Table 1 gives $467,181 in first-year evacuation savings; the Methods’ estimate of $1,054 per civilian referral and the 100 prevented referrals reported in the abstract yield $105,400. The citing sentence does not distinguish the projected monthly figures from the observed first-year totals, and the source describes regression analysis rather than a cost-minimization analysis. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

A retrospective analysis of dermatology cases referred by MSF field doctors revealed that only 10 of 65 cases (15%) had patient follow-up data, with two cases of patient death.

“A retrospective analysis of dermatology cases referred by MSF field doctors revealed that only 10 of 65 cases (15%) had patient follow-up data with two cases of patient death.41”

• cites [41] 41. Delaigue S, Morand JJ, Olson D, Wootton R, Bonnardot L. Teledermatology in low-resource settings: The MSF experience with a multilingual tele-expertise platform. Front Public Health 2014;14;2:233. sourceSupported

May combine two claims.

The percentage of avoided face-to-face visits ranged from 7.4% to 78%, with most studies reporting between 22% and 68% reductions in face-to-face specialist visits.

“The lowest was 7.4% 43 and the highest 78%, 36 with most studies reporting between 22% and 68% reductions in face-to-face specialist visits.”

• cites [43] 43. McGeady JB, Blaschko SD, Brajtbord JS, Sewell JL, Chen AH, Breyer BN. Electronic preconsultation as a method of quality improvement for urological referrals. Urolog Pract 2014;1:172-175. sourceSupported
• cites [36] 36. Marcolino MS, Alkmim MB. Teleconsultations to provide support for primary care practitioners and improve quality of care-The experience of a large scale telehealth service in Brazil. Stud Health Technol Inform 2015; 216:987. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Issues in communication refer to unclear specialist responses or expectations, which may be the result of unclear questions and expectations posed, or from an unclear understanding on how to use the program.

“Issues in communication refer to unclear specialist responses or expectations, which may be the result of unclear questions and expectations posed, 15 or from an unclear understanding on how to use the program.41”

• cites [15] 15. Gupte G, Vimalananda V, Simon SR, DeVito K, Clark J, Orlander JD. Disruptive innovation: Implementation of electronic consultations in a Veterans Affairs Health Care System. JMIR Med Inform 2016;4:e6. sourcePartly supported

  The Results (Qualitative Findings; page unavailable) report that two infrequent users were unfamiliar with the e-consult process, and leaders said substantial education was needed. The Discussion (Principal Findings; page unavailable) calls for better communication about the groups’ needs and expectations. The paper does not establish that unfamiliarity with the program caused unclear specialist responses or expectations. (LLM, conf=0.82)

  Experimental — accuracy not yet measured
• cites [41] 41. Delaigue S, Morand JJ, Olson D, Wootton R, Bonnardot L. Teledermatology in low-resource settings: The MSF experience with a multilingual tele-expertise platform. Front Public Health 2014;14;2:233. sourceSupported

May combine two claims.

Some challenges associated with eConsult were unclear directions from specialists, occasional lack of information or pertinent questions delivered to specialist by the PCP, and lack of patient follow-up.

“Some challenges associated with eConsult were those relating to unclear directions from specialists, an occasional lack of information or pertinent questions delivered to specialist by the PCP, and lack of patient follow-up.41”

• cites [41] 41. Delaigue S, Morand JJ, Olson D, Wootton R, Bonnardot L. Teledermatology in low-resource settings: The MSF experience with a multilingual tele-expertise platform. Front Public Health 2014;14;2:233. sourcePartly supported

  The Results (Survey results; page unavailable) identify poor clinical information from referrers and lack of patient follow-up feedback as concerns. Table 3 (Materials and Methods, Survey; page unavailable) also records one complaint about a specialist answer that was not well adapted, but it does not establish that specialist directions were unclear or that referrers failed to ask pertinent questions. The paper concerns MSF teledermatology rather than eConsult generally. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Fort et al. reported that many specialists participating in the Safety Net Specialty Care eConsult Program in Denver Metropolitan Area believed there was room to expand the program beyond the current volume of eConsults, although this perception varied by department, with high-volume or lower-staff-ratio departments expressing interest in maintaining the program at its current size.

“Fort et al. reported that many of the specialists participating in the Safety Net Specialty Care eConsult Program in Denver Metropolitan Area believed there was room to expand the program beyond the current volume of eConsults, although this perception varied by department, with high-volume or lower-staff-ratio departments expressing interest in maintaining the program at its current size.52”

• cites [52] 52. Fort MP, Namba LM, Dutcher S, Copeland T, Bermingham N, Fellenz C, et al. Implementation and evaluation of the safety net specialty care program in the Denver Metropolitan area. Permanente J 2017;21:16-22. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

One study determined the median time for patient notification after eConsult and found it to be 3 days.

“study determined the median time for patient notification after eConsult and found it to be 3 days.18”

• cites [18] 18. Pecina JL, Frank JM, North F. A retrospective study on how primary care providers manage specialists' recommendations after an e-consultation. SAGE Open Med 2016;4:2050312116682127. sourceSupported

May combine two claims.

While an RCT demonstrated the potential of eConsult for reducing adverse cardiovascular outcomes, two retrospective studies reported potential for harm due to lack of patient follow-up.

“While an RCT demonstrated the potential of eConsult for reducing adverse cardiovascular outcomes, 39 2 retrospective studies reported potential for harm due to lack of patient follow-up.40,41”

• cites [39] 39. Olayiwola JN, Anderson D, Jepeal N, Aseltine R, Pickett C, Yan J, et al. Electronic consultations to improve the primary care-specialty care interface for cardiology in the medically underserved: A cluster-randomized controlled trial. Ann Fam Med 2016;14:133-140. sourceSupported
• cites [40] 40. Price EL, Sewell JL, Chen AH, Sarkar U. Minding the gaps: Assessing communication outcomes of electronic preconsultation exchange. Jt Comm J Qual Patient Saf 2016;42:341-354. sourceNot checked — no full text of the source
• cites [41] 41. Delaigue S, Morand JJ, Olson D, Wootton R, Bonnardot L. Teledermatology in low-resource settings: The MSF experience with a multilingual tele-expertise platform. Front Public Health 2014;14;2:233. sourcePartly supported

  The Materials and Methods section (Confidentiality and security; page unavailable) identifies this work as a retrospective chart review. Results (Case characteristics; page unavailable) report that only 10 cases had follow-up data, and the Discussion (Limitations of the study; page unavailable) says the missing information prevented assessment of the system’s overall impact. The paper does not report that lack of patient follow-up caused harm; the RCT finding is attached to a different citation. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

Study designs varied with most studies (40%) classified as retrospective and cross-sectional (16%), and a smaller proportion of mixed method designs (7%) and randomized controlled trials (7%).

“Study designs varied with most studies (40%) classified as retrospective and cross-sectional (16%), and smaller proportion of mixed method designs (7%) and randomized controlled trials (RCTs; 7%).”

Probably not a substantial claim: may not pass S3 (load-bearing).

eConsult services were implemented on a variety of technological platforms.

“eConsult services were implemented on a variety of technological platforms (Table 4).”

May combine two claims.

Only 7 (16%) studies described a single specialty service, which included services in dermatology, cardiology, and pulmonology.

“Only 7 (16%) studies described a single specialty service, which included services in the following specialty groups: dermatology, cardiology, and pulmonology.”

May combine two claims.

The majority of studies were conducted in the United States (44%) and Canada (28%), with some in Brazil (9%), Europe (Spain, Italy, Austria, The Netherlands; 7%), and Australia (2%).

“Table 2 shows that the majority of studies were conducted in the United States (44%) and Canada (28%), with some in Brazil (9%), Europe (Spain, Italy, Austria, The Netherlands; 7%), and Australia (2%).”

Probably not a substantial claim: may not pass S3 (load-bearing).

A search of target databases on May 11, 2017 revealed 1,021 citations.

“A search of target databases on May 11, 2017 revealed 1,021 citations.”

May combine two claims.

Endocrinology was the most frequently accessed specialty through eConsult at 19%, followed by dermatology (16%), hematology (9%), cardiology (9%), gastroenterology (8%), and neurology (7%).

“Figure 2 shows the distribution of top specialties accessed through eConsult, with endocrinology being the most frequently accessed at 19%, followed by dermatology (16%), hematology (9%), cardiology (9%), gastroenterology 8%), and neurology (7%).”

May combine two claims.

The breadth of specialty services offered has greatly expanded beyond dermatology, with most studies focused on multispecialty service (84%), ranging from 8 to 86 specialties.

“The breadth of specialty services offered has greatly expanded beyond dermatology, with most studies focused on multispecialty service (84%), ranging from 8 to 86 specialties.”

May combine two claims.

The number of eConsults reported ranged from 65 to 217,014, and the number of participating providers ranged from 17 to 4,260 PCPs and 4 to 479 specialists.

“The number of eConsults reported ranged from 65 to 217,014, and number of participating providers ranged from 17 to 4,260 PCPs and 4 to 479 specialists.”

May combine two claims.

Multiple articles describing six eConsult services accounted for 67% (n = 29) of the articles: 30% (n = 13) from Champlain BASE, 9% (n = 4) from TNMG, 7% (n = 3) from Mayo Clinic, 7% (n = 3) from San Francisco General Hospital, 5% (n = 2) from UCSF, 5% (n = 2) from MSF, and 5% (n = 2) from VHA.

“There were multiple articles describing six eConsult services, which accounted for 67% (n = 29) of the articles: 30% (n = 13) from the Champlain BASE Ô eConsult service, 9% (n = 4) from the TNMG (Telehealth Network of Minas Gerais) in Brazil, 7% (n = 3) from the Mayo Clinic, 7% (n = 3) from San Francisco General Hospital, 5% (n = 2) from the University of California San Francisco (UCSF), 5% (n = 2”

May combine two claims.

Most articles described eConsult for PCP-specialist communication, with only one reporting on specialist-to-specialist communication.

“Most articles described eConsult for PCP-specialist communication, with only one reporting on specialist-to-specialist communication.10”

• cites [10] 10. North F, Uthke LD, Tulledge-Scheitel SM. Internal e-consultations in an integrated multispecialty practice: A retrospective review of use, content, and outcomes. J Telemed Telecare 2015;21:151-159. sourceNot checked — no full text of the source

May combine two claims.

eConsult's educational value was noted in several studies, with 90% of providers reported having learned from eConsult, whereas in others 74% reported their questions were answered, and 89% thought eConsult results were conclusive.

“eConsult's educational value was noted in several studies, with 90% of providers reported having learned from eConsult, 37 whereas in others 74% reported their questions were answered, 35 and 89% thought eConsult results were conclusive.47”

• cites [37] 37. Thijssing L, van der Heijden JP, Melissant CF, Chavannes NH, Witkamp L, Jaspers MW. Telepulmonology and telespirometry. In: Lovis C, et al., eds. e-Health-For continuity of care. Amsterdam: IOS Press; 2014:211-215. sourceNot checked — no full text of the source
• cites [35] 35. Alkmim MB, Marcolino MS, Maia JX, Pessoa CG, Machado E, Sousa L. Clinical quality control of a large-scale teleconsultation service. Stud Health Technol Inform 2015;216:988. sourceNot checked — no full text of the source
• cites [47] 47. Segura BT, Bustabad S. A new form of communication between rheumatology and primary care: The virtual consultation. Reumatol Clin 2016;12:11-14. sourceNot checked — no full text of the source

May combine two claims.

Providers reported that psychiatric eConsults increased access to specialty consultations for mental health and improved support for diagnosis and treatment.

“Providers also reported that psychiatric eConsults increased access to specialty consultations for mental health and improved support for diagnosis and treatment.48”

• cites [48] 48. Golberstein E, Kolvenbach S, Carruthers H, Druss B, Goering P. Effects of electronic psychiatric consultations on primary care provider perceptions of mental health care: Survey results from a randomized evaluation. Healthc (Amst) 2018;6:17-22. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Another study suggested a potential for millions in transportation saving by implementing eConsult to minimize face-to-face consultations.

“Finally, another study suggested a potential for millions in transportation saving by implementing eConsult to minimize face-toface consultations.12”

• cites [12] 12. Kirsh S, Carey E, Aron DC, Cardenas O, Graham G, Jain R, et al. Impact of a national specialty e-consultation implementation project on access. Am J Manag Care 2015;21:e648-e654.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

In Price et al.'s assessment of patient harm from electronic referrals to a gastroenterology clinic that did not result in scheduling, within resolved referrals, only nine patients (9%) received unplanned care while awaiting scheduling decisions, five of whom experienced harm related to referral complaints.

“Within referrals considered resolved (where the referral complaints have been resolved or addressed), only nine patients (9%) received unplanned care while awaiting scheduling decisions, five of whom experienced harm that was related to referral complaints, although authors noted that scheduling of appointments may not have avoided this harm.”

• cites [40] 40. Price EL, Sewell JL, Chen AH, Sarkar U. Minding the gaps: Assessing communication outcomes of electronic preconsultation exchange. Jt Comm J Qual Patient Saf 2016;42:341-354. sourceNot checked — no full text of the source

May combine two claims.

The authors of the gastroenterology referral study concluded that the few adverse outcomes observed were not due to communication lapses in the referral process, but rather to being unintentionally left unscheduled with evidence for discontinuity of care and lack of patient or provider follow-up.

“The authors concluded that the few adverse outcomes that were observed were not due to communication lapses in the referral process, but rather to being unintentionally left unscheduled with evidence for discontinuity of care and lack of patient or provider follow-up.”

• cites [40] 40. Price EL, Sewell JL, Chen AH, Sarkar U. Minding the gaps: Assessing communication outcomes of electronic preconsultation exchange. Jt Comm J Qual Patient Saf 2016;42:341-354. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Alkmim (2015, reference 34) was rated weak quality in the systematic review.

“| Alkmim 34 | 2015 | Brazil | Multispecialty | Cross-sectional | 1,954 | Factors associated with | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Olayiwola (2016, reference 39) was rated moderate quality in the systematic review.

“| Olayiwola 39 | 2016 | United States | Single specialty | Cluster-randomized | 19 PCPs (control), 17 | Specialist response time, | Moderate |”

May combine two claims.

While a wider breadth of specialty services are now being offered by many eConsult services worldwide, which may enable a wider population to obtain access to specialty care, there are still significant gaps in understanding the impact of the service on population health using traditional measures of mortality, morbidity, and clinical outcomes.

“While a wider breadth of specialty services are now being offered by many eConsult services worldwide, which may enable a wider population to obtain access to specialty care, there are still significant gaps in understanding the impact of the service on population health using traditional measures of mortality, morbidity, and clinical outcomes.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Nami (2015, reference 50) was rated weak quality in the systematic review.

“| Nami 50 | 2015 | Italy and Austria | Single specialty | Clinical trial | 391 Patients | Concordance between | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Cruz (2015, reference 17) was rated weak quality in the systematic review.

“| Cruz 17 | 2015 | United States | Multispecialty | Program evaluation 158 eConsults | Response time changes in | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Bonnardot (2014, reference 45) was rated weak quality in the systematic review.

“| Bonnardot 45 | 2014 | Global (MSF) | Multispecialty | Retrospective | 1,039 Telemedicine | Response time, provider | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Delaigue (2014, reference 41) was rated weak quality in the systematic review.

“| Delaigue 41 | 2014 | Multicountry (Sudan, | Single specialty | Retrospective | 65 Teledermatology | Response time, areas for | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Lin (2016, reference 46) was rated weak quality in the systematic review.

“| Lin 46 | 2016 | Global (NMCP) | Multispecialty | Teleconsultation | 585 Teleconsultations Referral/medevac | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Marcolino (2015, reference 36) was rated weak quality in the systematic review.

“| Marcolino 36 | 2015 | Brazil | Multispecialty | Observational | 63,975 | Referral avoidance, | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Rodriguez (2015, reference 13) was rated strong quality in the systematic review.

“| Rodriguez 13 | 2015 | United States | Multispecialty | Quality improvement | 15 Veteran patients, | Provider satisfaction, | Strong |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Scheibe (2015, reference 51) was rated moderate quality in the systematic review.

“| Scheibe 51 | 2015 | United States | Multispecialty | Retrospective chart | 2,105 eReferrals | Volume/appropriateness | Moderate |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Fort (2017, reference 52) was rated weak quality in the systematic review.

“| Fort 52 | 2017 | United States | Multispecialty | Mixed methods | 10 Patients, 18 safety | Patient satisfaction, | Weak |”

May combine two claims.

In general, the cost studies yield promising findings in terms of cost savings to the healthcare systems, return of investment, and societal savings.

“In general, these studies yield promising findings in terms of cost savings to the healthcare systems, return of investment, and societal savings.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Segura (2016, reference 47) was rated weak quality in the systematic review.

“| Segura 47 | 2016 | Spain | Multispecialty | Observational | 938 Virtual consults, | Avoidance of referrals, | Weak |”

May combine two claims.

In the authors' own recent study, all patients interviewed expressed acceptance for eConsult as a model for improving access to specialist care, had largely positive experiences with it as a model of care delivery, and supported its use in their future care.

“In our own recent study, we interviewed patients who have had an eConsult done on their behalf by their PCP and reported that all patients expressed acceptance for eConsult as a model for improving access to specialist care, had largely positive experiences with it as a model of care delivery, and supported its use in their future care.55”

• cites [55] 55. Joschko J, Liddy C, Moroz I, Reiche M, Crowe L, Afkham A, et al. Just a click away: Exploring patients' perspectives on receiving care through the Champlain BASE Ô eConsult service. Fam Pract 2018;35:93-98. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Fogel (2016, reference 20) was rated weak quality in the systematic review.

“| Fogel 20 | 2016 | Canada | Multispecialty | Cross-sectional | 436 Hematology | Avoidance of referrals, | Weak |”

May combine two claims.

Open-ended input responses revealed that most providers appreciated the service, finding it safe, timely, easy to use, beneficial to patient care, and capable of improving communication and facilitating provider education.

“Open-ended input responses revealed that most providers appreciated the service, finding it safe, timely, easy to use, beneficial to patient care, and capable of improving communication and facilitating provider education.25”

• cites [25] 25. Johnston DL, Murto K, Kurzawa J, Liddy C, Keely E, Lai L. Use of electronic consultation system to improve access to care in pediatric hematology/ oncology. J Pediatr Hematol Oncol 2017;39:e367-e369. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Pecina (2016, reference 18) was rated weak quality in the systematic review.

“| Pecina 18 | 2016 | United States | Multispecialty | Retrospective study 1,041 eConsults | Follow-up of | Weak |”

May combine two claims.

While the majority of new research examined outcomes related to patient and provider experience, the population health and cost measures continue to be limited and require further development.

“While the majority of new research examined outcomes related to patient and provider experience, the population health and cost measures continue to be limited and require further development.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Kirsh (2015, reference 12) was rated moderate quality in the systematic review.

“| Kirsh 12 | 2015 | United States | Multispecialty | Observational cohort 217,014 eConsults | Growth of eConsults by | Moderate |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Gupte (2016, reference 15) was rated weak quality in the systematic review.

“| Gupte 15 | 2016 | United States | Multispecialty | Observational quality | 7,097 eConsults | Provider experience, | Weak |”

May combine two claims.

The results to date indicate that eConsult systems have expanded significantly internationally and are largely multiservice in nature.

“The results to date indicate that eConsult systems have expanded significantly internationally and are largely multiservice in nature.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Liddy (2015, reference 22) was rated weak quality in the systematic review.

“| Liddy 22 | 2015 | Canada | Multispecialty | Economic analysis | 235 PCPs, 27 | Cost savings | Weak |”

May combine two claims.

Although the few studies which assessed specialist experiences found them to be positive in terms of perceived impact on patient, ease of use, improving access, and usefulness, one identified challenge was the potential for an increase in workload for specialists, along with potential issues in communication.

“Moreover, although the few studies which assessed specialist experiences found them to be positive (i.e., in terms of perceived impact on patient, ease of use, improving access, usefulness), one identified challenge was the potential for an increase in workload for specialists, along with the potential for issues in communication.30”

• cites [30] 30. Keely E, Drosinis P, Afkham A, Liddy C. Perspectives of Champlain BASE specialist physicians: Their motivation, experiences and recommendations for providing eConsultations to primary care providers. Stud Tech Health Inform 2015;209:38-45. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Byrom (2016, reference 42) was rated weak quality in the systematic review.

“| Byrom 42 | 2016 | Australia | Single specialty | Retrospective case | 406 Telederm cases | Response time, | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Maddry (2014, reference 38) was rated weak quality in the systematic review.

“| Maddry 38 | 2014 | United States (note: | Multispecialty | Retrospective | 99 Teleconsultations | Response time, type, and | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Golberstein (2017, reference 48) was rated weak quality in the systematic review.

“| Golberstein 48 | 2017 | United States | Multispecialty | Cluster-randomized | 72 Control PCPs, 70 | Effect of eConsult on PCP | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Liddy (2016, reference 24) was rated weak quality in the systematic review.

“| Liddy 24 | 2016 | Canada | Multispecialty | Cross-sectional | 1,796 eConsults | Response time, impact of | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Murthy (2017, reference 27) was rated weak quality in the systematic review.

“| Murthy 27 | 2017 | Canada | Multispecialty | Retrospective | 224 Infectious | eConsult response time, | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Price (2016, reference 40) was rated weak quality in the systematic review.

“| Price 40 | 2016 | United States | Multispecialty | Chart review | 266 eReferrals | Reasons for not | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Liddy (2016, reference 29) was rated weak quality in the systematic review.

“| Liddy 29 | 2016 | Canada | Multispecialty | Cross-sectional | 93 PCPs | Response time, provider | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by McGeady (2014, reference 43) was rated weak quality in the systematic review.

“| McGeady 43 | 2014 | United States | Multispecialty | Retrospective chart | 1,705 eReferrals, 487 | Avoidance of referrals, | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Liddy (2016, reference 23) was rated weak quality in the systematic review.

“| Liddy 23 | 2016 | Canada | Multispecialty | Costing evaluation | 3,487 eConsults | Costs and potential | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The impact of eConsult services on specialists is an understudied area in need of further attention.

“Similarly, the impact of eConsult services on specialists, although deemed fairly positive by a few articles, is another understudied area in need of further attention, especially since there is a potential for increases in workload, which could affect quality of care.30”

• cites [30] 30. Keely E, Drosinis P, Afkham A, Liddy C. Perspectives of Champlain BASE specialist physicians: Their motivation, experiences and recommendations for providing eConsultations to primary care providers. Stud Tech Health Inform 2015;209:38-45. sourceNot checked — no full text of the source

May combine two claims.

A majority of studies assessed patient experience of care from a PCP perspective, which points to a need to measure patient experience directly.

“A majority of studies assessed patient experience of care from a PCP perspective, which points to a need to measure patient experience directly.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Pecina (2016, reference 19) was rated weak quality in the systematic review.

“| Pecina 19 | 2016 | United States | Multispecialty | Retrospective | 5,115 eConsults | Reason for face-to-face | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Datta (2015, reference 14) was rated weak quality in the systematic review.

“| Datta 14 | 2015 | United States | Single specialty | Randomized clinical | 196 Patients | Total and per participant | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Shehata (2016, reference 28) was rated weak quality in the systematic review.

“| Shehata 28 | 2016 | Canada | Multispecialty | Retrospective | 394 eConsults 151 | Avoidance of traditional | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Liddy (2016, reference 31) was rated weak quality in the systematic review.

“| Liddy 31 | 2016 | Canada | Multispecialty | Mixed methods | 4,260 eConsults | eConsult patterns and | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Marcolino (2016, reference 33) was rated weak quality in the systematic review.

“| Marcolino 33 | 2016 | Brazil | Multispecialty | Ecological study | 73,698 | Provider satisfaction, | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Alkmim (2015, reference 35) was rated weak quality in the systematic review.

“| Alkmim 35 | 2015 | Brazil | Multispecialty | Randomized | 640 Teleconsultations Objectivity, courtesy, | Weak | |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Nelson (2016, reference 49) was rated weak quality in the systematic review.

“| Nelson 49 | 2016 | United States | Single specialty | Prospective study | 196 Teledermatology | Impact on diagnosis and | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Johnston (2017, reference 25) was rated weak quality in the systematic review.

“| Johnston 25 | 2017 | Canada | Multispecialty | Cross-sectional | 85 eConsults | Provider satisfaction, | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Liddy (2015, reference 21) was rated weak quality in the systematic review.

“| Liddy 21 | 2015 | Canada | Multispecialty | Mixed-methods | 2,052 eConsults | Satisfaction, education, | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Keely (2015, reference 30) was rated weak quality in the systematic review.

“| Keely 30 | 2015 | Canada | Multispecialty | Survey | 34 Specialists | Provider experience/ | Weak |”

May combine two claims.

In contrast to the previous review, the authors found an increased international presence of eConsult and noted that the breadth of specialty services offered has greatly expanded beyond dermatology, with most studies (84%) focused on multispecialty and only a handful addressing a single specialty service.

“In contrast to the previous review, we have found an increased international presence of eConsult and noted that the breadth of specialty services offered has greatly expanded beyond dermatology, with most studies (84%) focused on multispecialty and only a handful of studies addressing a single specialty service.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by North (2015, reference 10) was rated weak quality in the systematic review.

“| North 10 | 2015 | United States | Multispecialty | Retrospective review 3,008 eConsults, 2,885 | Conversion of eConsults to | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study by Barnett (2017, reference 44) was rated weak quality in the systematic review.

“| Barnett 44 | 2017 | United States | Multispecialty | Retrospective | 3,060 PCPs | Access, patterns of use, | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

C.L. and I.M. performed a second abstract screen to further eliminate or include articles for full screening.

“C.L. and I.M. performed a second abstract screen to further eliminate (or include) any articles for full screening.”

Classified as probably not a substantial claim.

A total of 43 studies were used for data extraction after limiting publication dates to 2014-present, excluding articles not published in English or French, and removing duplicates and ineligible articles.

“A total of 43 studies were used for data extraction after limiting publication dates to 2014-present, excluding articles not published in English or French, and removing duplicates and ineligible articles (Fig. 1).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Two reviewers screened abstracts for relevancy, with a third reviewer verifying 15 of the screened articles for rigor.

“Two reviewers (A.M. and N.N.) screened the abstracts for relevancy, with a third reviewer (I.M.) verifying 15 of the screened articles for rigor.”

May combine two claims.

In Northern Ireland, in the first 6 months of 2017, 71.6% of patients waited longer than 9 weeks and 24.2% waited more than 52 weeks to see a specialist.

“In Northern Ireland, statistics from the first 6 months of 2017 revealed that 71.6% of patients waited longer than 9 weeks to see a specialist and 24.2% waited more than 52 weeks.”

• cites [3] 3. UK Department of Health. Northern Ireland waiting time statistics: Outpatient waiting times quarter ending June 2017. London: UK Department of Health, 2017. www.health-ni.gov.uk/sites/default/files/publications/health/hs-niwts- outpatient-waiting-times-q1-17-18.pdf (last accessed March 21, 2018).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

The systematic review protocol was registered on PROSPERO (CRD42017069139).

“The protocol was registered on PROSPERO.2017,CRD42017069139.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The search was conducted on May 11, 2017 through OVID Medline, EMBASE, ERIC, and EBSCO CINAHL.

“On May 11, 2017 we conducted a search through OVID of Medline (from 1946), EMBASE (from 1947), and ERIC (1965 to April 2017) and through EBSCO of CINAHL.”

• AssumptionRests on an assumption: The search strategy and databases identified all relevant studies on eConsult published since the previous review.

Probably not a substantial claim: may not pass S3 (load-bearing).

A modified version of the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies by Thomas et al. was used to assess the quality of articles.

“A modified version of the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies by Thomas et al. 8 was used to assess the quality of articles.5”

• cites Thomas et al. 8Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Full articles were screened for relevancy by N.N. and A.M.

“Full articles were then screened for relevancy by N.N. and A.M.”

May combine two claims.

In Canada, 56% of patients waited at least 4 weeks to see a specialist, a trend consistent since 2010 and significantly higher than the Commonwealth Fund average of 36%.

“In Canada, 56% of patients waited at least 4 weeks to see a specialist, a trend that has remained consistent since 2010 and is significantly higher than the Commonwealth Fund average of 36%.”

• cites [1] 1. Canadian Institute for Health Information. How Canada compares: Results from the Commonwealth Fund's 2016 International Health Policy Survey of Adults in 11 countries. Ottawa: CIHI, 2017. www.cihi.ca/sites/default/files/document/text- alternative-version-2016-cmwf-en-web.pdf (last accessed March 21, 2018).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

In England, in the first 7 months of 2017, 89.4% of patients waited up to 18 weeks to see a specialist, failing the standard of 92% of patients waiting no more than 18 weeks.

“A recent wait time report in England showed that in the first 7 months of 2017, 89.4% of patients waited up to 18 weeks to see a specialist.This result failed to meet their standard of 92% of patients waiting no more than 18 weeks for their consult.2”

• cites [2] 2. NHS England. Statistical Press Notice: NHS referral to treatment (RTT) waiting times data August 2017. London: NHS, 2017. www.england.nhs.uk/statistics/ wp-content/uploads/sites/2/2017/06/RTT-statistical-press-notice-PDF-300K- 51515.pdf (last accessed March 21, 2018).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

No articles were excluded based on the quality assessment.

“We did not exclude any articles based on the quality assessment.”

• AssumptionRests on an assumption: The included studies' reported outcomes are reliable enough to support the review's conclusions despite most being categorized as weak.

May combine two claims.

There is a potential for increases in workload, which could affect quality of care.

“Similarly, the impact of eConsult services on specialists, although deemed fairly positive by a few articles, is another understudied area in need of further attention, especially since there is a potential for increases in workload, which could affect quality of care.30”

• cites [30] 30. Keely E, Drosinis P, Afkham A, Liddy C. Perspectives of Champlain BASE specialist physicians: Their motivation, experiences and recommendations for providing eConsultations to primary care providers. Stud Tech Health Inform 2015;209:38-45. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

The paucity of RCTs reflects the early, emerging nature of this health technology.

“First, the paucity of RCTs reflects the early, emerging nature of this health technology.”

May combine two claims.

Comparing eConsult wait times to the traditional referral pathway for face-to-face visits, which are at least 4 weeks in Canada, eConsults provide a promising alternative.

“Comparing these wait times to those typically experienced with a traditional referral pathway for face-to-face visits with a specialist, which are at least 4 weeks in Canada, 1 eConsults provide a promising alternative.”

• cites [1] 1. Canadian Institute for Health Information. How Canada compares: Results from the Commonwealth Fund's 2016 International Health Policy Survey of Adults in 11 countries. Ottawa: CIHI, 2017. www.cihi.ca/sites/default/files/document/text- alternative-version-2016-cmwf-en-web.pdf (last accessed March 21, 2018).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

eConsult services in this review were shown to be effective in providing faster access to specialists' advice, with short response times of participating specialists and resulting in substantial avoidance of face-to-face referral visits.

“eConsult services in this review were shown to be effective in terms of providing faster access to specialists advice, with short response times of the participating specialists and resulting in substantial avoidance of face-to-face referral visits.”

May combine two claims.

Unlike other e-health technology solutions, eConsult services show sustained use and spread, high adoption, and little pushback from providers who use them, as evidenced by high provider satisfaction ratings.

“Unlike other e-health technology solutions, eConsult services show sustained use and spread, high adoption, and little pushback from the providers who use them, as evidenced by high provider satisfaction ratings.25”

• cites [25] 25. Johnston DL, Murto K, Kurzawa J, Liddy C, Keely E, Lai L. Use of electronic consultation system to improve access to care in pediatric hematology/ oncology. J Pediatr Hematol Oncol 2017;39:e367-e369. sourceNot checked — no full text of the source

May combine two claims.

Reports of provider education, quality of responses/feedback, and impact on healthcare support and workload suggest the provider experience is generally positive and point out that eConsult has the potential to improve overall job satisfaction, retention in remote communities, and provide educational/continuing professional development opportunities.

“Furthermore, reports of provider education, quality of responses/feedback, and impact on healthcare support and workload, 37 suggest the provider experience is generally positive in these domains and point out that eConsult has the potential to improve overall job satisfaction, retention in remote communities, and provide educational/continuing professional development opportunities.”

• cites [37] 37. Thijssing L, van der Heijden JP, Melissant CF, Chavannes NH, Witkamp L, Jaspers MW. Telepulmonology and telespirometry. In: Lovis C, et al., eds. e-Health-For continuity of care. Amsterdam: IOS Press; 2014:211-215. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The review rated Shipherd 2016 as Weak.

“| Shipherd 11 | 2016 | United States | Multispecialty | Feasibility program | 303 eConsults, 230 | Time spent responding to | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The review rated Thijssing 37 2014 as Weak.

“| Thijssing 37 | 2014 | The Netherlands | Single specialty | Descriptive study | 227 Telespirometry | Referral avoidance, impact | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The review rated Tran 26 2016 as Weak.

“| Tran 26 | 2016 | Canada | Multispecialty | Cross-sectional | 1,055 eConsults | Impact of question type | Weak |”

Probably not a substantial claim: may not pass S3 (load-bearing).

The review rated Tran 32 2016 as Moderate.

“| Tran 32 | 2016 | Canada | Multispecialty | Cross-sectional | 180 PCPs, 464 | Provider satisfaction, | Moderate |”