We used a convergent parallel mixed-methods study design consisting of a retrospective chart review of completed e-consults and a series of interviews with PCPs. The overall approach to the study was a pragmatic one, seeking practical solutions for programmatic change that triangulated between the quantitative and qualitative results, as well as the existing literature [16]. Quantitative and qualitative analyses were completed separately and integrated, looking for both convergence and divergence of findings [17] to inform recommendations. Research ethics approval was obtained from the Women’s College Hospital Research Ethics Board.

Between January 1, 2015, and March 31, 2016, among all e-consults submitted across all specialty areas, 3.66% (49/1339) e-consults were submitted for psychiatry on the 2 platforms: 4.2% (38/887) on the government-funded platform and 2.4% (11/452) on the private platform. Out of the psychiatric e-consults, 78% (38/49) were obtained from the psychiatrists for review. Of them, one e-consult had been declined and resubmitted to another psychiatrist; thus, it was counted only once. The e-consults represented 37 different patients from 30 unique PCP referrers (ranging from 1 to 5 e-consults each). The 5 psychiatrists answered between 1 and 25 e-consults each. The consultant knew the patient from a previous encounter in only one of the cases. Table 2 displays referral characteristics. Most requests (86%, 32/37) were submitted by family physicians, with 14% (5/37) coming from nurse practitioners. The years of practice of the referrers ranged from 1 to 42 years. Patients were mostly female (65%, 24/37), ranging in age from 15 to 90 years. A diverse range of diagnoses were represented, with more than half (57%, 21/37) of referrals having two or more diagnoses documented. The most common referral question was about medication side effects or safety (70%, 26/37), followed by psychiatric symptom management (59%, 22/37; Table 3). Most questions about medication side effects or safety pertained to antidepressants, followed by antipsychotics, lithium, stimulants, and benzodiazepines. Questions about side effects or safety can be clustered into 3 main groups: (1) medical complications (eg, weight gain, hypothyroidism, sexual dysfunction), (2) safety in special populations (eg, pregnant, elderly, pediatric), and (3) psychiatric complications (eg, manic switch, suicidal ideation). Referrers provided various attachments for the specialist to review (Table 3).

Most e-consults (81%, 30/37) were responded to within 24 hours and nearly two-thirds (65%, 24/37) were answered with a single exchange between referrer and consultant (Table 3). Among the 8 cases where the consultant suggested a referral to a specialist for assessment, 5 were for psychiatry, 2 for cognitive behavioral therapy, and 1 for endocrinology. Consultants frequently suggested or attached provider and patient resources, which often included e-resources (Table 3).

Previous experience with e-consult among interviewed PCPs varied from minimal to frequent use. Participants described preferred general conditions for the use of e-consult such as “quick,” “simple” questions to a consultant who is reliable in responding promptly. They also discussed the preference for e-consult to be integrated with electronic medical records for ease of use, and a desire for short, unstructured forms. Several themes specific to perceptions regarding e-consult for psychiatry were identified.

For the most part, the quantitative and qualitative data converged and could be interpreted to yield 5 recommendations for future uptake and expansion of e-consult between PCPs and psychiatrists.

First, PCPs can be educated regarding the feasibility and promptness of e-consult in receiving psychiatric advice. They should also be given examples regarding the types of requests that can be addressed using e-consult.

Second, the primary use for psychiatric e-consult is mostly for seeking pharmacological advice. Unless specified before, this may cover any and all psychiatric disorders and medication classes. The e-consult service needs to be adequately staffed with questions appropriately directed to the most knowledgeable specialists.

Third, PCPs, who are new to practice and who are from rural areas, may be more receptive to psychiatric e-consult, but not exclusively, as long wait times for specialist care are universal.

Fourth, in mental health care, where community services and social determinants of health are important, e-consult psychiatrists ideally must have familiarity or relationships with the communities, and wherever possible with the providers, that their patients consult to.

Fifth, given the potential nuances of the psychiatric patient, e-consult should be integrated with other psychiatric services including telephone consultation and face-to-face assessment either in-person or by telemedicine, as well as with methods of communicating for ongoing collaboration.

E-consult for psychiatry accounted for 4% of all e-consults on the 2 platforms that we studied, and represented nearly all psychiatric diagnostic categories. Most e-consults were addressed in a single exchange and completed within 24 hours. The quantitative and qualitative data converged to yield recommendations for the implementation, integration, and staffing of the psychiatry e-consult service to optimize utility and uptake.

Our finding that 4% of all e-consults were for psychiatry is strikingly similar to the findings in previous reports [6]. This percentage represents underutilization of e-consults, given the high proportion of individuals with mental illness who seek care in primary practice [14,15]. In our qualitative data, we found that PCPs perceived that e-consult had limited utility in psychiatric issues, which were considered more nuanced, and preference was given to face-to-face assessment of these patients. Similar to this finding, a US study reported a recommendation for an in-person assessment in a quarter of psychiatry e-consults [18], and another US study found a higher rate of conversion to face-to-face visits for psychiatry e-consults than other medical specialties [13]. These findings support that e-consult is not a complete solution but could and should facilitate stepped care approaches to ensure access to the right care at the right time. We observed that the most common actual and suggested use for psychiatry e-consult was medication advice, consistent with the findings of another descriptive study of psychiatry e-consults [18]. We also found that PCPs who are from rural areas and those who are new to practice are more likely to be receptive to using psychiatry e-consult, reflecting differential adoption of technology and program change based on geography, age, and experience [19]. Ultimately, many of the recommendations that we arrived at are applicable to e-consult more broadly and have been described by others disciplines, such as expansion to be a part of the triage and referral pathway [5,20], and for comanagement [5].

A limitation of this study was that data were collected too early during the implementation of both the e-consult platforms, which may not be generalizable to more established services or services that function in different ways. Our sample sizes were not large, but the volumes of e-consults were similar to the volumes that have been reported for other platforms during their early use [6,18]. Furthermore, for generating recommendations regarding future directions for psychiatry e-consult, we feel that the quantitative data were sufficiently informative, and that the themes from the qualitative interviews were saturated and triangulated well with the existing literature [6,13,19] and our personal experience with continued use of e-consult. By maximum variation sampling, we were able to identify pertinent provider differences amidst the common themes. Although we reported on the content of psychiatrist’s response, we did not assess the quality of these responses or the actual rate at which recommendations were followed by the PCPs.

For health care technology, a key facilitator of adoption is the proof of utility [19]. We specifically undertook this study due to the issues of patient complexity and PCP skepticism that we encountered with respect to e-consultation for psychiatry. Empirical data that support the benefits of e-consult are emerging, and our study has identified some factors that could be optimized for improving the utility and the uptake of e-consults between PCPs and psychiatrists. Within current resource-constrained environments, new models of integrated care for mental illness are needed to improve quality of care for patients. Although overall access to psychiatry needs to be improved [21], the psychiatrist who specializes in complex mental health problems can typically offer advice with an e-consult to PCPs, and enhance their feeling of support while caring for their patients [12]. Additional study of the impact on patient outcomes and costs is required, along with established characteristics of a good e-consult psychiatrist and features of an effective e-consult. Resource considerations are essential as compensation and practice models are not often well aligned to incentivize novel methods of communication and collaboration.