Virtual links to the emergency department

We wish to congratulate the authors for this well done study on an important research question: they found that an electronic link between an ED and family physicians produced no effect.1

In eHealth, failure to use technology is frequently observed, and is an important outcome.2 The authors of this study should report access and usage by the family physicians; if the communication software was infrequently used, it would not have changed outcomes.

Our second area of concern is the choice of family physicians eligible to participate. 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. The average practice size for physicians in the study is 4184 patients.1 In Ontario, the Family Health Network contract limits groups to an average practice size of 2400 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 and if these results are applicable outside of settings with limited computer usage and high practice volumes.