Impact of an electronic link between the emergency department and family physicians: a randomized controlled trial

Eddy Lang; Marc Afilalo; Alain C. Vandal; Jean-François Boivin; Xiaoqing Xue; Antoinette Colacone; Ruth Léger; Ian Shrier; Stephen Rosenthal

doi:10.1503/cmaj.050698

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In response
Eddy Lang

Posted on: 30 May 2006
Electronic link: was lack of effectiveness due to low usage?
Michelle Greiver

Posted on: 16 February 2006
Communication: Improving Resource Use or Retaining Human Resources?
Laura K Muldoon

Posted on: 06 February 2006

Posted on: (30 May 2006)
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In response
Eddy Lang
Dear CMAJ editorial board,
We welcome the comments of Dr. Muldoon and could not agree more with her perspective. As an emergency department led research initiative the primary study outcome that was emphasized related to factors that impacted the most on ED functioning and resource utilization. While these results were disappointing we also measured the impact of the electronic link on measures of continuity o...
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Dear CMAJ editorial board,
We welcome the comments of Dr. Muldoon and could not agree more with her perspective. As an emergency department led research initiative the primary study outcome that was emphasized related to factors that impacted the most on ED functioning and resource utilization. While these results were disappointing we also measured the impact of the electronic link on measures of continuity of care such as family physician (FP) confidence and management plans as enhanced by the information received and general measures of physician satisfaction. These results are very favorable and are currently in submission to a major biomedical journal.
We also are thankful for Drs. Greiver and Eisenbach’s astute observations. We do in fact have extensive data on the utilization of the electronic communication tool by the 23 family physicians recruited in the study. Our information is derived from electronic log-in records and informs us about the number of times that each patient report was accessed by the intended family physician recipient. Overall, physicians accessed these reports 2.1 times per patient visit. Subsequent log-ins were frequently needed as e-mail updates would be sent out if a pending result became available i.e. a bacterial culture. In our view, this represents a moderate to high level of utilization of the application. We agree that the sheer volume of patients that community family physicians in our busy urban setting have to manage may preclude an effective change in practice resulting from electronic linkage information. Unfortunately, reduced access to primary care physicians has created a new normal in practice size for many physicians and it is our view that if this intervention’s impact on resource use cannot be appreciated when FPs are receiving several reports a month on their most needy patients we are doubtful that an impact would be measurable if the reports were issued only a few times a year.
Eddy Lang, Marc Afilalo, Ruth Leger
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (16 February 2006)
Page navigation anchor for Electronic link: was lack of effectiveness due to low usage?
Electronic link: was lack of effectiveness due to low usage?
Michelle Greiver
We wish to congratulate the authors for this well done study, on an important research question. It was the subject of a recent CATCH-IT (Critically Appraised Topics in Communication, Health Informatics, and Technology) presentation at the Centre for Global eHealth, University of Toronto.
We have questions for the authors. It would have been interesting to find out to what degree the software was actually used....
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We wish to congratulate the authors for this well done study, on an important research question. It was the subject of a recent CATCH-IT (Critically Appraised Topics in Communication, Health Informatics, and Technology) presentation at the Centre for Global eHealth, University of Toronto.
We have questions for the authors. It would have been interesting to find out to what degree the software was actually used. Physicians received emails at 7 am; how many check their email daily? Were the links to the ED charts followed? Hospital databases can be audited, and can track who views the data, and when they see it. Could the authors comment on access and usage by the family physicians involved in this study? The authors note that only 14% had “very much” experience with computers, and we do not know how many use an Electronic record in their practice (which would help to integrate the data into the patient record). If the communication software was infrequently used it would have been unlikely to change outcomes.
Our second area of concern centers around the choice of family physicians eligible to participate. Every study involves compromises to ensure feasibility. The authors chose physicians with the highest number of patient visits to emergency; the 43 eligible physicians likely represent about 10% of all family physicians at their institution. Comparing their characteristics with those of their peers may be worthwhile. Appendix 1 in the on-line version gives baseline physician characteristics; the average practice size is 4,184 patients. These are very large practices; in Ontario, the Family Health Network contract limits groups to an average practice size of 2,400 patients for full payment. Participants also had older patients (33% age 70 and older), with significant numbers of patients having chronic illnesses (49%), and being co-managed by specialists (39%). It is possible that the volume and difficulty of their daily practice precluded change even with better communication. We wonder if the results would have been different with a more representative physician population.
The authors conclude that “an electronic Web-based tool for transmitting clinical information from the emergency department to the primary care network does not appear to reduce resource utilization in either milieu.”1 We question whether this statement is applicable outside of settings with limited computer usage and high practice volumes.
Michelle Greiver Department of Family and Community Medicine University of Toronto
Gunther Eysenbach Senior Scientist, Centre for Global eHealth Innovation Toronto General Research Institute of the UHN
1. Lang E, Afilalo M, Vandal AC, Boivin J-F, Xue X, Colacone A, et al. Impact of an electronic link between the emergency department and family physicians: a randomized controlled trial CMAJ. January 9, 2006 cmaj.050698.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (6 February 2006)
Page navigation anchor for Communication: Improving Resource Use or Retaining Human Resources?
Communication: Improving Resource Use or Retaining Human Resources?
Laura K Muldoon
Lang et al were quite optimistic in their expectations of the power of communication between the Emergency Department and Family Physicians. We all want to reduce duplication and un-necessary admissions to hospital, but these are not the benefits of an electronic communication system which would attract me as a practicing Family Doctor. Instead, I would applaud the time I would save in not having to hound hospitals for...
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Lang et al were quite optimistic in their expectations of the power of communication between the Emergency Department and Family Physicians. We all want to reduce duplication and un-necessary admissions to hospital, but these are not the benefits of an electronic communication system which would attract me as a practicing Family Doctor. Instead, I would applaud the time I would save in not having to hound hospitals for information and the increased comfort I would feel in knowing what had actually happened to my patient in the Emergency Department. As we read more frequently in the popular press, Family Physicians are leaving practice in droves. Having timely information to make clinical decisions, whether or not the decisions actually change because of it, is one factor which can help to make Family Practice more palatable.
Conflict of Interest:
None declared
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Competing Interests: None declared.