Objective To provide an overview of the use of and evidence for eConsult in correctional facilities worldwide.
Design Scoping review.
Data sources Three academic databases (MEDLINE, Embase and CINAHL) were searched to identify papers published between 1990 and 2020 that presented data on eConsult use in correctional facilities. The grey literature was also searched for any resources that discussed eConsult use in correctional facilities. Articles and resources were excluded if they discussed synchronous, patient-to-provider or unsecure communication. The reference lists of included articles were also hand searched.
Results Of the 226 records retrieved from the academic literature search and 595 from the grey literature search, 22 were included in the review. Most study populations included adult male offenders in a variety of correctional environments. These resources identified 13 unique eConsult services in six countries. Six of these services involved multiple medical specialties, while the remaining services were single specialty. The available evidence was organised into five identified themes: feasibility, cost-effectiveness, access to care, provider satisfaction and clinical impact.
Conclusions This study identified evidence that the use of eConsult in correctional facilities is beneficial and avoids unnecessary transportation of offenders outside of the facilities. It is feasible, cost-effective, increases access to care, has an impact on clinical care and has high provider satisfaction. Some gaps in the literature remain, and we suggest further research on patient satisfaction, enablers and barriers to implementation, and women, youth and transgender populations in this setting to inform service providers and stakeholders. Despite some gaps, eConsult is evidently an important tool to provide timely, high-quality care to offenders.
- Quality in health care
- PRIMARY CARE
- INTERNAL MEDICINE
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. Questions about data, its collection and the analysis can be directed to the corresponding author, Dr Clare Liddy, at firstname.lastname@example.org.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
To our knowledge, our scoping review is the first to focus on asynchronous, provider-to-provider communication in correctional facilities, as others have primarily examined synchronous models or those providing patient-to-provider communication.
The methodology used for this scoping review was transparent and rigorous, providing an extensive summary of the academic and grey literature regarding electronic consultation use in correctional facilities.
This review did not limit studies by country of publication, allowing for contributions from a broad scope (worldwide) to highlight eConsult’s generalisability and scalability.
The publicly available grey literature search results often did not evaluate the use of eConsult in correctional facilities, and we did not follow-up with institutions for data supporting their use.
Offenders in correctional facilities experience poorer health outcomes than the general population and face significant challenges in accessing specialist care.1–6 In Canada, offenders were found to have higher rates of latent tuberculosis, sexually transmitted infections, hepatitis C, HIV and other blood-borne infections,6 which may require specialist care. Similar findings have been reported in other countries.7–9 Many factors affect offenders’ ability to access prompt specialty care, including the logistical, financial and safety considerations around their travel outside of the institution,10 and the remote location of many correctional facilities with limited access to healthcare workers.4 However, offenders’ time in correctional facilities provides an opportunity to improve their health, which could lead to secondary benefits to society, such as decreasing healthcare costs and improving health in the general population.6
Several approaches to improve access to care in correctional facilities have been implemented, including real-time/synchronous (eg, video conferencing) telehealth and telemedicine tools to facilitate communication between patients and providers, or between primary care providers (PCPs) and specialists. However, real-time synchronous video visits require high-bandwidth telecommunication and adequate image quality/resolution for accurate diagnoses.10 11 This can pose a challenge for correctional facilities, particularly in Canada, where these institutions tend to be located in rural and remote areas12 where access to high-speed internet could pose a challenge.13 Thus, asynchronous/store-and-forward telemedicine tools may be better suited for these settings.
In Canada, Ontario eConsult has been developed to improve timely access to specialist advice. Electronic consultation (eConsult) is a secure web-based tool that allows PCPs, including physicians and nurse practitioners, to communicate asynchronously with specialists about a patient’s care, often eliminating the need for an in-person specialist visit.14 Ontario eConsult and other such services have been shown to reduce wait times, improve access to specialist advice and reduce costs in community settings.15–18 These benefits have also been demonstrated in long-term care, whose population faces similar challenges in accessing external care.19 20 Moreover, a study describing utilisation of the infectious disease specialty service through Ontario eConsult identified tuberculosis, hepatitis and sexually transmitted infections, which are prevalent in the corrections population, within the top 10 reasons for use.21 As eConsult use expands across Canada, the potential benefits of using eConsult in Canadian correctional facilities should be explored.
Thus, the objective of this review is to provide an overview of the use of and evidence for eConsult in correctional facilities worldwide. The results will facilitate discussions between Correctional Services Canada (CSC) and the Ontario eConsult Centre of Excellence about implementing a nationwide eConsult service in correctional facilities, and inform the use of eConsult as a tool in correctional facilities worldwide.
This study follows the scoping review methodological framework proposed by Arksey and O’Malley.22 At each stage of the study, we held meetings with key stakeholders, including healthcare professionals and policymakers from CSC (figure 1). Stakeholders provided input on study design and interpretation of findings.
While a variety of terms are used in the literature to describe electronic consultation (eg, e-consultation, teleconsultation, tele-expertise), for the purposes of this study we will use the term ‘eConsult’ to refer to the web-based communication and ‘eConsult service’ to refer to the platform that offers this web-based communication. Our review consisted of three parts: academic literature search, grey literature search and forward snowballing.
Academic literature search
On 9 July 2020, we conducted a literature search of three academic databases: MEDLINE, Embase and CINAHL. The searches in MEDLINE and Embase were built and run through Ovid, and the search in CINAHL was built and run through EBSCOhost. Titles published from January 1990 to July 2020 in English and French were included. We did not limit our search by country of study. The major search concepts that defined the Subject Heading terms and Keywords are Corrections and Electronic Consultation. The lists of Subject Headings and Keywords were developed through an initial review of articles and in consultation with a health sciences librarian at the University of Ottawa (online supplemental appendix A, B).
Articles were included if they presented data on eConsult use in correctional settings. eConsult was defined as a secure, asynchronous communication that allows PCPs (defined as family physicians, nurse practitioners, physician assistants or any medical doctor who considered themselves to deliver primary care) to request advice from specialists or allied health services, such as dentistry or pharmacy. Articles were included if they discussed any type of corrections environment (eg, minimum security facilities, mental health facilities and Indigenous facilities).
We excluded literature on synchronous communication modalities (eg, real-time video visits or telephone consults); patient-to-provider communication; and email, social media-based or web-based communication that was not explicitly stated as secure or described using synonymous terms. We also excluded studies if the communication was strictly one-way and did not allow for iterative communication between providers. Abstracts, commentaries and reviews that did not present data on an eConsult service were also excluded.
Two reviewers (English: CS and MH-S; French: SK and CS) independently screened each abstract. The full texts of all abstracts deemed potentially relevant were screened for inclusion. To ensure reliability of the full-text screening, reviewers CS and MH-S independently reviewed the same 10 randomly selected English full-text articles and checked for agreement. A third reviewer (SK) was consulted to resolve disagreements. Once a high level of agreement was attained, the remaining full-text articles were each screened by one of the reviewers (English: CS and MH-S; French: SK and CS).
The following information was extracted from each article to a data charting form by one of the reviewers: publication title, author, year, study type/design, country, study objective/purpose, description of the electronic consultation intervention, single versus multispecialty service, setting, study population, sample size, outcome measures, main findings and additional notes.
Grey literature search
The grey literature was searched on 6 August 2020. First, the keywords developed for the academic literature search (online supplemental appendix A) were combined using Boolean terms in the Google search engine (online supplemental appendix C). Screening was limited to the first 10 pages of results. Next, advanced site searches of government websites, organisations and academic conferences identified by stakeholders were performed through the Google search engine using the same keywords. The government websites of the USA, UK, Ireland and Australia were searched for information about eConsult use in correctional facilities, as these countries were suggested by our CSC stakeholders. Relevant resources were sought from the WHO, Federal Bureau of Prisons, CSC, RubiconMD, HubMD and Capplaw organisations. Finally, the websites of two annual academic conferences, ‘Custody and Caring’ held by the University of Saskatchewan and the ‘American Correctional Association Conference’, were searched to identify any relevant abstracts. The advanced Google searches were also limited to the first 10 pages of results.
All results were screened by webpage title and description preview in the Google search engine. Any articles or resources that discussed eConsult use in correctional facilities were recorded, and data were extracted to the data charting form. Articles were included if they discussed any type of corrections environment, a secure, asynchronous eConsult and involved provider-to-provider communication. Exclusion criteria were the same as those for the academic literature search.
The reference lists of included articles were reviewed for any relevant resources that were not captured by our search. Articles about relevant research studies described in published conference abstracts or grey literature were sought through targeted searches of the Google search engine. This involved searching for the authors of the study or the name of the eConsult service, if available. If no results were found, authors were contacted by email. Any available information was extracted to the data charting form.
After data extraction, characteristics of included academic articles, intervention descriptions and main findings were summarised and tabulated. The available evidence from evaluation of eConsult in correctional settings was categorised under five naturally emerging themes. The included articles were not subject to quality appraisal, as this is not typically done during scoping review studies22 and given the diversity of literature obtained from the above sources, much of which was not academic.
Patient and public involvement
No patient involved.
The results have been organised into the following categories: overview of included literature, landscape of eConsult in correctional facilities and evaluation of eConsult and available evidence.
Overview of included literature
Academic literature search
The electronic search of the three databases yielded 226 non-duplicate records for title and abstract screening. Eighty-five articles were included for full-text review, nine of which were included in the review (figure 2).10 23–30 No additional articles were identified by screening the reference lists of the included articles. The included studies were published between 2001 and 2018. The study designs of included articles displayed large variation, with the plurality being cost analysis studies (n=3). Other study types were descriptive (n=2), pilot (n=1), retrospective cohort (n=1), cross-sectional retrospective chart review (n=1) and cross-sectional (n=1). Study populations included adult offenders (n=7),10 23–27 30 youth offenders (n=1)28 and female offenders (n=3).25 27 30 The correctional environments described in the included studies were mixed, with variation from maximum security prisons to juvenile detention facilities. Details of included studies are available in table 1.
Grey literature search
The grey literature search yielded 595 total results: 100 generated by the initial keyword search; 127 from the advanced site search of the relevant government websites; 347 from the advanced site search of relevant organisations identified; and 21 from the advanced site search of the two academic conferences. After screening the webpage title and description previews, 22 resources were included for full-webpage review. A total of 13 resources were retained for data extraction.31–43
Landscape of eConsult in correctional facilities
The 22 included resources from the academic and grey literature searches indicated widespread use of eConsult in correctional facilities worldwide. From these resources, we identified 13 unique eConsult services implemented in the USA (n=7), Australia (n=2), France (n=1), Canada (n=1), Brazil (n=1) and Colombia (n=1). The literature from Canada discussed a teledermatology service, the Champlain BASE eConsult service, and the Ontario eConsult Program. These services are now combined under Ontario eConsult, and thus reported as one unique service. A map of these services can be found in figure 3. The types of eConsult services were quite mixed, with around half being multispecialty (n=6). The most common single specialty services were dermatology (n=2) and ophthalmology (n=2). The other single specialty services provided communication with psychiatry, specifically regarding depression (n=1), hepatology, specifically regarding hepatitis C virus (n=1) and dentistry (n=1). Details of the eConsult services identified through the academic and grey literature searches and their impact are available in table 2.
Case example: teledermatology using WebDCR
The French teledermatology service using WebDCR by the SESAN group is one example of a successful eConsult service that has been well-described in the academic literature.25 27 30 The earliest form of this particular service was established in 2008, with the initial pilot study published in 2016.27 The service is still active at the time of this publication. In 2018, Zarca et al demonstrated that this single specialty dermatology service enabled timely access to specialist advice, with a median response time of 5 days.30 For the physicians at the correctional facility, most eConsult requests (85%) were initiated in less than 30 min. For the dermatologists responding to the request, most eConsult cases (90%) were completed in less than 30 min. eConsult was shown to be feasible in this setting, with 88% of requests having a satisfactory or very satisfactory picture quality and 82% of patients having a completed treatment plan. In contrast, less than half (35%) of patients had a completed treatment plan in the control group (face-to-face appointment). Only 3% of the cases with satisfactory eConsult requests required a face-to-face consultation or hospitalisation for further investigation. The service was also found to be well accepted among physicians, with all responders in agreement that they would like to continue using the teledermatology service.
Evaluation of eConsult and available evidence
The academic literature describes a variety of outcome measures assessed to evaluate eConsult services in correctional settings. Most of the grey literature resources simply identified the use of eConsult in a correctional facility and did not include evaluation data. Though reported in several resources,31–34 37 38 40 much of the data were not from evaluations specific to corrections environments. In the grey literature, preliminary results from evaluation of a unique eConsult service in correctional settings are only available for Ontario eConsult, Federal Bureau of Prisons and the eHealth system for hepatitis C virus treatment.33 40 43 Available evidence is summarised under five identified themes: feasibility, cost-effectiveness, access-to-care, provider satisfaction and clinical impact. The main findings of individual studies are summarised in table 2.
Feasibility of eConsult use in correctional settings was evaluated by assessing providers’ ability to operate the technology platform and any additional equipment needed, amount of human resources required, number of encounters initiated, time spent by each provider on the platform, quality of images captured (where appropriate), accuracy of diagnoses and quality of the assessment/information provided via eConsult. These outcome measures were assessed in nine studies.10 24–28 30 33 43 eConsult was shown to be feasible in correctional facilities, with minimal time required by providers in the facilities to initiate an encounter and high-quality advice and accurate diagnoses provided by specialists. Gavigan et al showed there is high agreement between dermatological diagnoses provided following in-person assessment versus eConsult assessment.26 Similarly, there is high agreement between traditional in-person dental examinations and asynchronous teledentistry examinations.28 In another study, the authors reported that dermatologists spent an average of 8 min per case and responded to 10 consultations per week.27 However, the teledentistry study reported some challenges related to obtaining images, including poor lighting of certain areas and time-consuming training to produce good quality dentistry photographs.28
A commonly studied outcome measure was cost-effectiveness (n=6).10 23 24 29 30 42 It was specifically examined in some articles via annual transports avoided, annual appointment costs avoided and investment and operating costs of the eConsult equipment (some eConsult services required additional equipment in the correctional facility, such as imaging instruments). Many of these studies were conducted using hypothetical or simulation models. eConsult was found to be cost-effective in all six studies, as it decreases the cost of care and reduces transport of offenders outside of correctional facilities. Cusack et al found that the cost savings from ‘store-and-forward’ (ie, asynchronous) consultation outweigh implementation costs.42 A simulation study modelled the hypothetical use of eConsult for ophthalmology, which highlighted the effectiveness of diabetic retinopathy diagnoses, cost savings and timeliness of the response (<24 hours) as some of the main benefits. The authors of the study demonstrated that teleophthalmology costs less for each quality-adjusted life year (QALY) gained compared with non-teleophthalmology (US$882/QALY vs US$947/QALY, respectively).23 Another simulation study discussed lower associated costs with store-and-forward models.29 Using a store-and-forward telehealth model, 411 000 transports between correctional facilities and physician offices in the USA could be avoided annually, resulting in an annual cost avoided of US$162 million. However, it should be noted that a hybrid store-and-forward/real-time video model was found to be the most cost-effective, as additional transports could be avoided.29 42
Reimbursement and funding are also important considerations when discussing cost-effectiveness. Reimbursement was discussed in two studies,10 23 with variations in different countries. Only one study discussed funding for eConsult.30 Zarca et al. indicated that their teledermatology service was funded by the Paris Regional Health Agency.30
Access-to-care was assessed in five studies based on the specialists’ response time and breadth of specialities available.10 24 25 30 33 eConsult was found to improve access to care through timely diagnosis and treatment. From the five studies, the median specialist response time to answer the eConsult question ranged from 2.9 hours to 5 days. The multispecialty eConsult service specified that the top three most accessed specialty groups were dermatology, cardiology and haematology.33
Two studies examined providers’ satisfaction with eConsult and it was found to be high.30 43 Satisfaction was measured 6 months post-intervention with 90% of physicians willing to continue using eConsult.30 In the other study, specialists and general practitioners reported high usability and acceptability of an eHealth model of care that included eConsult. It was noted that nurses reported suboptimal usability and lower acceptability scores of the entire eHealth model, but the majority of nurses rated the specialist consultation (ie, eConsult) component as useful or very useful.43
Several articles (n=6) reported on the clinical results of the eConsult, such as the number or proportion of eConsult cases with a diagnosis provided, request for additional assessments/tests made, advice provided, treatment plans recommended and face-to-face visit still needed or recommended.10 23–25 30 43 In one study, the proportion of patients with a completed treatment plan was 82% compared with only 35% when eConsult was not used.30 Another study reported that adherence to guideline-based care was significantly higher in those using eConsult compared with the standard-of-care.43 Finally, eConsult resulted in reduced need for appointments, as only one of six scheduled in-person appointments was still needed after the consultation.10
This scoping review identified 13 unique eConsult services used in correctional facilities across six countries, including Canada.26 32 33 Findings from the academic and grey literature searches were consistent, in that they are overwhelmingly positive and support use of eConsult in the correctional setting. Comparisons between synchronous and asynchronous models supported the use of asynchronous eConsult-type communication for correctional facilities.24 29 While eConsult is currently operating in many correctional facilities, most offer access to a single specialty group only, suggesting that expansion of multispecialty eConsult services could improve offenders’ access-to-care.
eConsult was shown to be feasible and effective in corrections facilities. Several consistent benefits were reported in the literature. Primarily, eConsult improves access to specialist advice for offenders, allowing for timely diagnosis, management and treatment. Furthermore, eConsult significantly reduces costs of care through avoided transportation of offenders outside of the facility for in-person appointments that are often no longer needed. This also improves safety for offenders, guards accompanying offenders to appointments, providers and the public.31 eConsult has high provider satisfaction and allows for provision of high-quality specialist advice. Likewise, the timeliness of advice received through eConsult was highlighted as a key benefit, with consistent evidence of a median response time of less than 5 days. This is particularly important for offenders, who are in most cases incarcerated for only a short time.30 Notably, the median length of incarceration in Canada is less than 1 month,44 while the average wait time for patients to see a specialist in-person is 5.2 months.45 As a result, many offenders may not receive an appointment until after they have re-entered the community, increasing the likelihood of missed visits and poor continuity of care, and further exacerbating the poor health outcomes associated with this group.6 eConsult allows many of these patients to receive specialist-informed care on a shorter timeline, thereby improving the quality and equity of healthcare for offenders and reducing the risks of care disruption. Similar results have been reported in related literature reviews46 and ongoing studies.43
Though evidence in the academic literature is highly favourable of eConsult in correctional settings, some potential challenges for implementation have been identified in commentaries, including regulatory issues, start-up costs, administrative support, training and technical difficulties.47–49 For example, Fletcher discussed the difficulties of receiving adequate funding in correctional facilities for start-up costs, such as purchasing basic equipment and improving telecommunication networks.47 The academic literature reported limitations of eConsult involving time-consuming training, costs of high data-transfer speeds, and any necessary equipment or required infrastructure. However, the tone in the literature suggests these challenges are surmountable and outweighed by the benefits that have been previously mentioned. For example, despite the concerns noted in the teledentistry study, there was high agreement between in-person and remote examination assessments, suggesting that eConsult is feasible and does not compromise clinical examination.28 Although there are some concerns regarding the quality of clinical experience,41 studies on eConsult have shown that in-screen interpretation is as reliable as hard copy interpretation, given proper equipment and training.50 Furthermore, start-up costs will vary in different regions based on the presence of pre-existing technical infrastructure that meets security and privacy requirements.51 In our region, registration and ability to use the Champlain BASE eConsult Service requires minimal training.52 Start-up costs are low due to the presence of pre-existing technical infrastructure for the service and the lack of additional equipment required, such as specialised video equipment, beyond an internet-enabled device.51
The methodology employed for this scoping review was rigorous and transparent. To our knowledge, our review is the first to focus on asynchronous, provider-to-provider communication in correctional facilities, as others have primarily examined synchronous models53 or those providing patient-to-provider communication.46 Another aspect of its novelty is the examination of the academic and grey literature across a broad scope (worldwide). However, we recognise some limitations. The grey literature search results were compiled from publicly available online resources, which included limited evaluation of the identified eConsult services in correctional settings at the time the search was conducted. We did not follow-up with institutions to find more data supporting their use. Furthermore, we only searched the government websites of four countries, which was a convenience sample suggested by our CSC stakeholders. Given the increasing attention to telemedicine and digital health services during the COVID-19 pandemic, we also recognise there will be value in conducting an updated search in coming years to include literature published after July 2020. Regardless, this scoping review presents an overview of existing literature and evidence on the topic, which will be useful to healthcare administrators, policymakers, eConsult providers, clinicians providing care in correctional facilities, offenders living in these facilities and their advocates.
Although this review identified promising evidence supporting eConsult use in correctional facilities, there remain several aspects requiring further evaluation. While some studies discussed patient satisfaction,24 43 data supporting these findings are limited due to low-response rates and should be examined in more detail. Cost-effectiveness should also be studied in more detail, as most of these findings from the academic literature were based on simulation and modelling studies rather than from the implementation of eConsult. As the majority of offenders with access to eConsult are adult men, an assessment of the unique challenges facing women, youth or transgender offenders is warranted. In addition to these topics, future research should more closely examine individual eConsult services established in correctional settings to identify key enablers, considerations and barriers for implementation, in addition to those previously identified in the literature.47 48 These should be considered in individual jurisdictions by service providers and addressed prior to full-service implementation.
Reviews of the health of offenders in Canada, USA, Australia and several other countries have demonstrated a gap in the research on this population.54 55 This may be due to the ethical challenges associated with the collection of health data for corrections populations, including power differentials between offenders and staff in correctional facilities as well as researchers; maintaining the safety and security of both researchers and offenders; obtaining voluntary participation in research; protecting the privacy of offenders; and confidentiality of their personal information.56 Additionally, many offenders have mental illnesses;46 54 researchers must be aware of the consequences, such as the stigma, for those participating in mental health research.57 These considerations should be accounted for when planning future research involving this population.
Results of this scoping review will inform discussions between CSC and the Ontario eConsult Centre of Excellence about potential expansion of Ontario eConsult to correctional facilities across Canada. Our team is planning to conduct interviews with an interdisciplinary team of healthcare administrators, senior leadership, physicians, nurses and pharmacists from CSC involved in an ongoing pilot of Ontario eConsult in 13 facilities in Ontario to identify enablers and barriers specific to their sites. Learnings from those interviews will inform future implementation.
The existing evidence suggests that the use of eConsult in correctional facilities is feasible and beneficial, as it improves timely access to specialist advice for offenders, reduces the cost-of-care and avoids unnecessary transportation and security issues. To fill gaps in the current literature, future research should continue to assess patient satisfaction and cost-effectiveness; study the unique challenges faced by women, youth and transgender offenders and the unique benefits eConsult may offer these populations; and identify enablers and barriers to implementation of individual services. This information would better support organisations that may be interested in implementing eConsult in these specific contexts. Despite these gaps in our current knowledge, it is clear that eConsult will be an important tool for providing high quality, timely healthcare to offenders; thus, it should be a priority for decision makers and advocates to implement a nationwide service in correctional facilities across Canada, and in other jurisdictions worldwide.
Original protocol for the study
The original unpublished protocol for this study is included as a supplementary file (online supplemental appendix D).
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. Questions about data, its collection and the analysis can be directed to the corresponding author, Dr Clare Liddy, at email@example.com.
Patient consent for publication
The authors wish to thank Sarah Visintini for her assistance in developing the search strategy, and Justin Joschko for his assistance in editing the manuscript and preparing it for publication.
Contributors CS, MH-S, SK, EK and CL conceived of and designed the study. CS, MH-S and SK conducted data collection, analysis and reporting. All authors contributed to the analysis and interpretation of data. CS and MH-S drafted and revised the manuscript. SK, EK, JS and CL provided feedback and critical revisions for important intellectual content. All authors approved the final draft of the manuscript. CL is the guarantor and accepts full responsibility for the overall content.
Funding Funding for this study was provided by the Canadian Institutes of Health Research and the Ontario Ministry of Health and Long-Term Care.
Disclaimer The funders had no role in study design, data collection/analysis/interpretation or preparation of the manuscript.
Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographical or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.
Competing interests CL and EK are co-executive directors of the Ontario eConsult Centre of Excellence, funded by the Ontario Ministry of Health. They cofounded the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service but do not retain any proprietary rights. EK answers eConsults through the service, less than one per month.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.