Implementing an electronic consult system (eConsult) for specialty requests in safety-net health systems is associated with improved specialty care access but creates new challenges for primary care practitioners (PCPs), such as an increased burden of work in providing specialty care, according to a study published in JAMA Internal Medicine.

Michelle S. Lee, BA, from the Department of Health Care Policy at Harvard Medical School in Boston, and colleagues, conducted qualitative interviews of PCPs to understand their perceptions of the use of eConsult on PCP workflow, specialist access, and patient care. The interviews were conducted from December 1, 2016, to April 15, 2017, and included 40 safety-net PCPs in Los Angeles County. Interviewees were recruited to include diversity in PCP type, practice setting, and employer (DHS employed vs DHS affiliated). Participants were interviewed about their perceptions of clinical workflow, access to specialists, relationships with specialists, and referral decision making.

The primary outcome was perceptions of the results of eConsult, including positive and negative themes and remaining perceived gaps in specialty care.

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The researchers interviewed 40 PCPs, including 12 internists, 17 family practitioners, and 11 advanced practice clinicians. Of the 40 participants, 27 (68%) were women; 24 (60%) PCPs performed 5 or more eConsults per week. In discussing specialty care prior to eConsult implementation, PCPs described numerous challenges, including uncertainty after referral submission, long wait times, and no way to “curbside” or discuss patient care with specialists.

PCPs’ perceptions of eConsult focused on 4 main themes: access and timeliness of specialty care, shift of work to PCPs, relationships with specialists, and eConsult interface issues. Many PCPs praised the improved timeliness of specialist input with eConsult, as well as the added clinical and educational value of dialogue with specialists, particularly compared with the limitations of the prior referral process.

PCPs also consistently perceived that eConsult shifted some of the work of specialty care to them. Many PCPs believed that this extra burden was worth the effort given the benefits of eConsult, such as improved timeliness of care and ability to manage specialty conditions. In contrast, others were frustrated by the increased administrative burden, broadened clinical responsibility, and restructuring of specialty care delivery.

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“Many PCPs, particularly those who were enthusiastic about the mission of eConsult, believed that it improved the timeliness of specialty input and appreciated the opportunity to manage a broader spectrum of care,” the researchers concluded. “Others believed that eConsult slowed the process of obtaining a referral as the key goal and were frustrated by the need to follow specialists’ electronic suggestions. Our results highlight how delivery transformations can create new perceived barriers to care and resistance to change among frontline users.”


Lee MS, Ray KN, Mehrotra A, Giboney P, Yee HF, Barnett ML. Primary care practitioners’ perceptions of electronic consult systems: a qualitative analysis. JAMA Intern Med. Published online April 12, 2018. doi:10.1001/jamainternmed.2018.0738