Amir Afkham - Academia.edu (original) (raw)

Papers by Amir Afkham

Journal of Telemedicine and Telecare

Introduction The usual referral pathway is from a primary care provider (PCP) to a specialist; ho... more Introduction The usual referral pathway is from a primary care provider (PCP) to a specialist; however, specialists also refer to and consult with other specialists. Electronic consultation (eConsult) allows clinicians to submit questions on behalf of patients to specialists to receive timely advice. Most eConsult studies in the past have examined questions asked from PCPs to specialists. This study investigates the utilization of specialists submitting clinical questions to other specialists through the Ontario eConsult Service and identifies use-case scenarios where specialist-to-specialist eConsult may be beneficial. Methods A retrospective, descriptive, cross-sectional analysis of eConsults submitted by specialists through the Ontario eConsult Service for 24 months (March 2019 to February 2021). Utilization data is collected automatically by the service, including specialty referred to, time billed, region, and results from a closeout survey which includes the referral outcome o...

Objective: To describe the questions being asked through the Champlain BASE eConsults service and... more Objective: To describe the questions being asked through the Champlain BASE eConsults service and quantify the resulting reduction in referrals. We also identify topics to address at future CME events. Background: Access to Neurology consultation is limited by high demand and urgency of the presentation. The Champlain BASE (Building Access to Specialists through eConsultation) aims to increase access through direct communication between primary care providers (PCPs) and specialists. Rapid responses to PCP questions can guide management and sometimes relieve the need for a formal consultation. We reviewed which topics were frequently addressed, the types of questions asked, and the proportion of resulting diverted consults. Design/Methods: 387 consecutive questions submitted to the Champlain BASE service between May 2011 and January 2015 were categorized by topic and type of question and analyzed quantitatively. Data from routine utilization and exit survey completed by PCPs was analyzed. This included time required to answer each question and the resulting need for formal consultation. Results: The top 5 topics were headache (17%), incidental imaging findings (11%), numbness/tingling (11%), seizure (9%), and cerebrovascular disease (CVD) (9%). 51% were related to diagnosis (choice of test, imaging interpretation and symptom interpretation), 23% to drug treatment (choice, adverse effects, prescribing instructions), and 17% to management (general, need for referral). 88% of questions took under 10 minutes of specialist time to answer, and 80% were answered within one day. eConsults decreased face-to-face referrals by 50%. In 54% of cases, the PCP received information for a new course of action. Conclusions: We found that an eConsult service provides timely access to neurologists and can divert half of intended face-to-face consultations. The most common questions posed by PCPs regarded diagnosis and drug therapy of headaches, seizures, altered sensation and CVD. eConsults services could provide guidance for continuing medical education planning in neurology. Disclosure: Dr. Bradi has nothing to disclose. Dr. Sitwell has nothing to disclose. Dr. Liddy has nothing to disclose. Dr. Afkham has nothing to disclose. Dr. Keely has nothing to disclose.

Internal Medicine Journal, Oct 29, 2022

BackgroundGeneral internists in Canada are subspecialty providers in the inpatient and outpatient... more BackgroundGeneral internists in Canada are subspecialty providers in the inpatient and outpatient settings. Electronic consultations (eConsult) allow primary care providers (PCPs) to virtually consult specialists to address clinical questions. There is a paucity of literature examining the utility and benefits of eConsults by general internists.AimsTo determine how an eConsult service is used to access general internists.MethodsA retrospective cross‐sectional analysis of internal medicine cases was completed between 1 January 2016 and 31 December 2019 via the ChamplainBASE eConsult service. Two authors derived and validated a general internal medicine (GIM)–specific taxonomy using the validated: (i) Taxonomy of Generic Clinical Questions; and (ii) Internal Classification for Primary Care. Two hundred seventy‐six cases were coded following taxonomy validation. ChamplainBASE utilisation summary and closeout survey data were also analysed.ResultseConsults were responded to in a median of 3.1 days and took 15 min to complete. The eConsult's helpfulness and educational value were rated as 4 to 5/5 and often provided advice for a new or additional course of action. In‐person referral was avoided in 40% of cases. The majority of eConsults consisted of a single question (88%) related to diagnostic clarification. The median remuneration per eConsult was $50.ConclusionsThe majority of eConsults to general internists sought diagnostic clarification and confirmed the view of general internists as expert diagnosticians. eConsults cost less than an in‐person consultation and were viewed favourably by PCPs. Further research can consider the eConsult provider experience and whether eConsults should become a required part of GIM ambulatory practice.

Current Oncology, Nov 3, 2022

This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY

International Journal for Quality in Health Care, Sep 1, 2018

Open Medicine, Feb 1, 2012

The principle of symmetry-asymmetry is widely presented in the structural and functional organiza... more The principle of symmetry-asymmetry is widely presented in the structural and functional organization of the nonliving and living nature. One of the most complex manifestations of this principle is the left-right asymmetry of the human brain. The present review summarizes previous and contemporary literary data regarding the role of brain asymmetry in neuroimmunomodulation. Some handedness-related peculiarities are outlined additionally. Brain asymmetry is considered to be imprinted in the formation and regulation of the individual's responses and relationships at an immunological level with the external and internal environment. The assumptions that the hemispheres modulate immune response in an asymmetric manner have been confirmed in experiments on animals. Some authors assume that the right hemisphere plays an indirect role in neuroimmunomodulation, controlling and suppressing the left hemispheric inductive signals.

American Journal of Roentgenology, 2020

OBJECTIVE. The purpose of this study was to assess the use of an electronic consultation platform... more OBJECTIVE. The purpose of this study was to assess the use of an electronic consultation platform to connect primary care providers and radiologists and provide opportunities for valuable consultation regarding diagnostic imaging in patients, as well as to identify opportunities for targeted education surrounding high-yield radiology topics. MATERIALS AND METHODS. A retrospective review was performed of consultations conducted using the electronic platform from September 2012 to January 2017. Consultations were classified by subspecialty (neuroradiology, thoracic, abdominal, musculoskeletal, or pediatric radiology), question type (workup, surveillance, education, specialist referral query, discharge, or other), anatomy, and pathology. Feedback surveys were completed by primary care providers after each consultation to evaluate timeliness, value, and impact on patient care. RESULTS. A total of 302 consultations were reviewed. Subspecialty breakdown was as follows: abdominal, 94/302 (31%); neuroradiology, 74/302 (25%); musculoskeletal, 61/302 (20%); thoracic, 56/302 (19%); and pediatric, 17/302 (6%). The majority of consultations pertained to patient workup (112/302 [37%]), surveillance of imaging findings (95/302 [31%]), and provider education (48/302 [16%]). Cystic lesions (38/302 [13%]), pain (24/302 [8%]), and bone lesions (21/302 [7%]) were the most queried conditions. Patient management was altered in 167 cases (55%), and unnecessary testing was avoided in 84 (28%). Providers rated the perceived value of the electronic consultation system as excellent in 227 cases (75%). CONCLUSION. The electronic consultation system allowed primary care providers to easily consult with radiologists, was perceived as high value by primary care providers, resulted in altered patient management, and avoided unnecessary imaging tests. We identified follow-up imaging of cystic lesions and imaging workup of pain in patients as opportunities for continuing medical education for primary care providers.

BMC Geriatrics

Background Frailty is a complex age-related clinical condition that increases vulnerability to st... more Background Frailty is a complex age-related clinical condition that increases vulnerability to stressors. Early recognition of frailty is challenging. While primary care providers (PCPs) serve as the first point of contact for most older adults, convenient tools for identifying frailty in primary care are lacking. Electronic consultation (eConsult), a platform connecting PCPs to specialists, is a rich source of provider-to-provider communication data. Text-based patient descriptions on eConsult may provide opportunities for earlier identification of frailty. We sought to explore the feasibility and validity of identifying frailty status using eConsult data. Methods eConsult cases closed in 2019 and submitted on behalf of long-term care (LTC) residents or community-dwelling older adults were sampled. A list of frailty-related terms was compiled through a review of the literature and consultation with experts. To identify frailty, eConsult text was parsed to measure the frequency of f...

International Journal of Circumpolar Health, Nov 30, 2022

Open Forum Infectious Diseases, 2016

Canadian Journal of Neurological Sciences, Jun 1, 2018

Background: Migraines are sub-optimally treated, affect millions of Canadians, and are underrepre... more Background: Migraines are sub-optimally treated, affect millions of Canadians, and are underrepresented in medical training. A study was conducted to identify the needs of Canadian Healthcare Providers (HCPs) for migraine education, with the aim to inform the development of learning activities. Methods: This ethicsapproved study was deployed in two consecutive phases using a mixed-methods approach. Phase 1 (qualitative) explored the causes of challenges to migraine care via a literature review, input from an expert working group, and semi-structured interviews with multiple stakeholders. Phase 2 (quantitative) validated these causes using an online survey. Results: The study included 103 participants (28 in phase 1; 75 in phase 2): general practitioners=37; neurologists=24; nurses=14; pharmacists=20; administrators, policy influencers and payers=8. Four areas of sub-optimal knowledge were identified: (1) Canadian guidelines, (2) diagnostic criteria, (3) preventive treatment, and (4) non-pharmacological therapies. Attitudinal issues related to the management of migraine patients were also identified. Detailed data including the frequencies of knowledge gaps among general practitioners and general neurologists will be presented along with qualitative findings. Conclusions: Educational activities for general practitioners and general neurologists who treat patients with migraines should be designed to address the four educational needs described in this study.

Journal of Medical Internet Research, Jan 18, 2023

Background: Cancer poses a significant global health burden. With advances in screening and treat... more Background: Cancer poses a significant global health burden. With advances in screening and treatment, there are now a growing number of cancer survivors with complex needs, requiring the involvement of multiple health care providers. Previous studies have identified problems related to communication and care coordination between primary care providers (PCPs) and cancer specialists. Objective: This study aimed to examine whether a web-and text-based asynchronous system (eOncoNote) could facilitate communication between PCPs and cancer specialists (oncologists and oncology nurses) to improve patient-reported continuity of care among patients receiving treatment or posttreatment survivorship care. Methods: In this pragmatic randomized controlled trial, a total of 173 patients were randomly assigned to either the intervention group (eOncoNote plus usual methods of communication between PCPs and cancer specialists) or a control group (usual communication only), including 104 (60.1%) patients in the survivorship phase (breast and colorectal cancer) and 69 (39.9%) patients in the treatment phase (breast and prostate cancer). The primary outcome was patient-reported team and cross-boundary continuity (Nijmegen Continuity Questionnaire). Secondary outcome measures included the Generalized Anxiety Disorder Screener (GAD-7), Patient Health Questionnaire on Major Depression, and Picker Patient Experience Questionnaire. Patients completed the questionnaires at baseline and at 2 points following randomization. Patients in the treatment phase completed follow-up questionnaires at 1 month and at either 4 months (patients with prostate cancer) or 6 months following randomization (patients with breast cancer). Patients in the survivorship phase completed follow-up questionnaires at 6 months and at 12 months following randomization.

Journal of European Continuing Medical Education, Sep 2, 2022

Our study evaluates the impact of feedback sent to specialists participating in eConsult services... more Our study evaluates the impact of feedback sent to specialists participating in eConsult services. eConsult Specialists from two eConsult services in Ontario, Canada, received feedback on their use of eConsult via biannual specialist reports. An 11-item survey was developed to evaluate the impact, content, and distribution process of these specialist reports. We distributed 742 specialist reports in March 2021 and surveyed the specialists in July 2021. Our findings show that specialists largely felt that the feedback received validated their efforts (83%) and that receiving the report made them more likely to continue to participate in the eConsult service (59%). Most did not feel judged (74%) or distressed (79%) by the reports, and 72% said that reporting the median selfreported billing time did not impact their own billing times. Overall, eConsult services can capture, report and aggregate data valuable to specialists and is useful for Continuing Professional Development. Benefits and lack of risk implementing this type of feedback should encourage other services to consider similar processes.

Genetics in Medicine, Oct 1, 2022

Telemedicine Journal and E-health, May 1, 2020

Background: When implementing e-health solutions, effective integration into a clinic's exist... more Background: When implementing e-health solutions, effective integration into a clinic's existing processes is essential to facilitate adoption and sustained usage. Introduction: This article examines the effectiveness of adoption/utilization of an electronic consultation (eConsult) service by primary care providers (PCPs) using a "delegate model," through which referral clerks manage requests on behalf of PCPs, thereby reducing PCPs' administrative burden. Materials and Methods: We conducted a retrospective cross-sectional study of all eConsults submitted between May 1, 2013, and December 31, 2017, by the Bruyère Academic Family Health Team (FHT), after the clinic implemented the service using a delegate model. We assessed system utilization, including monthly volume of submitted eConsults, requested specialties, and impact on PCP referral behavior based on the mandatory closeout surveys. We also conducted a subanalysis to compare the volumes of eConsults per provider between the FHT and all other providers. Results: The Bruyère Academic FHT submitted 3,233 eConsult cases. Volume increased 3.5 fold, from 285 in the first year to 1,016 in the last year. Active Bruyère Academic FHT providers (those who submitted ≥3 cases in 6 months) submitted a median of 25 eConsults (interquartile range [IQR]: 14.75-35.25) versus 14 (IQR 8-24) for all other active users. In 36% of cases, a referral was originally contemplated but avoided based on specialist advice. In 5% of cases, the referral was not originally contemplated but deemed appropriate by the PCP based on specialist advice. Discussion: Our findings show high levels of eConsult use in the clinic utilizing a delegate model, which persisted throughout the study period and was reported to significantly reduce the backlog of traditional referrals at the clinic. Conclusions: The integration of eConsult capability into existing clinic operations was successful in that it allowed the PCPs to request eConsult using a familiar process, avoiding the challenges associated with adopting a new and unfamiliar technology.

Journal of the Canadian Association of Gastroenterology, May 17, 2018

Background: Wait times for gastroenterologists in Canada continue to exceed recommended targets. ... more Background: Wait times for gastroenterologists in Canada continue to exceed recommended targets. Electronic consultation (eConsult) may reduce the need for face-to-face gastroenterologist visits. Objective: The goal of this study was to identify the cases submitted to gastroenterologists though the Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service and explore their impact on primary care physicians' (PCPs) courses of action. Methods: Gastroenterology cases submitted between June 2013 and January 2015 were categorized using a modification of the International Classification for Primary Care (ICPC-2) taxonomy. Question type (e.g., diagnosis or management) was classified using a validated taxonomy. Results: Of the 121 gastroenterology consults reviewed, 33% were related to hepatology, 23% to GI symptoms, and 13% to specific luminal diseases. Among hepatology eConsults (n=40), 47% pertained to abnormal liver function testing. Overall, 51% of eConsults were related to diagnosis, 30% to management, 9% to drug treatments and 7% to procedures. PCPs received a reply within a median of 2.9 days. Only 25% of cases resulted in a face-to-face referral. Conclusions: The eConsult service provided timely, highly regarded advice from gastroenterologists directly to PCPs and often eliminated the need for a face-to-face consultation. An evaluation of the most commonly-posed questions could inform future continuing medical education activities for PCPs.

Endocrine Practice, Oct 1, 2016

Objective: To describe the impact of an eConsult service on access to endocrinologists along with... more Objective: To describe the impact of an eConsult service on access to endocrinologists along with its influence on changing primary care provider (PCP) course of action and referral behaviors. Methods: Established in 2011, the Champlain BASE (Building Access to Specialist Care via eConsult) service allows PCPs to access specialist care in lieu of traditional face-to-face referrals. We conducted a cross-sectional study of eConsult cases submitted to endocrinologists by PCPs between April 15, 2011 and January 31, 2015. Usage data and PCP responses to a mandatory closeout survey were analyzed to determine eConsult response times, PCP practice behavior, referral outcomes, and provider satisfaction. Each eConsult was coded according to clinical topic and question type based on established taxonomies. Results: A total of 180 PCPs submitted 464 eConsults to endocrinology during the study period. Specialist median response time was 7 hours, with 90% of responses occurring within 3 days. PCPs received a new or additional course of action in 62% of submitted cases. An unnecessary face-to-face referral was avoided in 44% of all eCon-sults and in 67% of cases where the PCP initially contemplated requesting a referral. Over 95% of cases were rated at least 4 out of 5 in value for PCPs and their patients. Conclusion: The use of eConsult improves access to endocrinologists by providing timely, highly rated practice-changing clinical advice while reducing the need for patients to attend face-to-face office visits.

Annals of Family Medicine, Mar 1, 2018

PURPOSE Excessive wait times for specialist appointments pose a serious barrier to patient care. ... more PURPOSE Excessive wait times for specialist appointments pose a serious barrier to patient care. To improve access to specialist care and reduce wait times, we launched the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service in April 2011. The objective of this study is to report on the impact of our multiple specialty eConsult service during the first 5 years of use after implementation, with a focus on growth and sustainability. METHODS We conducted a cross-sectional study of all eConsult cases submitted between April 1, 2011 and April 30, 2016, and measured impact with system utilization data and mandatory close-out surveys completed at the end of each eConsult. Impact indicators included time interval to obtain specialist advice, effect of specialist advice on the primary care clinician's course of action, and rate of avoidance of face-to-face visits. RESULTS A total of 14,105 eConsult cases were directed to 56 different medical specialty groups, completed with a median response time of 21 hours, and 65% of all eConsults were resolved without a specialist visit. We observed rapid growth in the use of eConsult during the study period: 5 years after implementation the system was in use by 1,020 primary care clinicians, with more than 700 consultations taking place per month. CONCLUSIONS This study presents the first in-depth look at the growth and sustainability of the multispecialty eConsult service. The results show the positive impact of an eConsult service and can inform other regions interested in implementing similar systems.

BACKGROUND The Ontario eConsult Service allows a primary care provider (PCP) to access specialist... more BACKGROUND The Ontario eConsult Service allows a primary care provider (PCP) to access specialist advice through two models: direct-to-specialist (DTS), where PCPs select a specialist from a directory, and BASE™ managed specialty service, where PCPs choose a specialty group and are assigned a specialist from a qualified pool based on availability. OBJECTIVE To examine patterns of use between the two models of eConsult delivery. METHODS We conducted a cross-sectional analysis of utilization data collected from eConsults completed between October 2018 and September 2019. Cases were grouped based on the model used for submission (i.e., BASE™ or DTS). Each model was assessed for the number of cases over time, proportion resulting in new/additional information, impact on PCP’s decision to refer, and billing time. RESULTS PCPs submitted 26,121 eConsults during the study period. Monthly case volume increased 43% over the duration of the study, primarily in the BASE™ model (69% vs 7% for DTS). PCPs were able to confirm a course of action that they originally had in mind in 41% of cases for both models, and received advice for a new or additional course of action in 55% (BASE™) and 56% (DTS) of cases. A referral was originally contemplated but avoided in 51% (BASE™) and 53% (DTS) of cases, originally contemplated and still needed in 20% (BASE™) and 18% (DTS), and neither originally contemplated or not needed in 22% (both models). 93% (n=24,354) had a response provided during the study time period. CONCLUSIONS Both eConsult models received strong uptake. Usage patterns varied between models, with the majority of growth occurring under BASE™, but survey responses showed that both models provided similar outcomes in terms of new information offered and impact on decision to refer. CLINICALTRIAL