Implementing an Opt-in eConsult Program at Seven Academic Medical Centers: a Qualitative Analysis of Primary Care Provider Experiences

BACKGROUND: Electronic consultation (eConsult), which involves primary care provider (PCP)-to-specialist asynchronous consultation, is increasingly used in health care systems to streamline care and to improve patient access. The Association of American Medical Colleges (AAMC) formed a collaborative to support the implementation of an electronic medical record (EMR)-based, opt-in eConsult program across multiple academic medical centers (AMCs). In this model, PCPs can elect to send either an eConsult or a traditional referral. OBJECTIVE: We sought to understand the PCP experience with eConsult to identify facilitators of and barriers to the successful adoption of the model. DESIGN AND PARTICIPANTS: We conducted 35 semi-structured interviews and 6 focus groups with a range of primary care providers at 7 AMCs participating in the AAMC collaborative. APPROACH: Interviews were recorded and transcribed or detailed field notes were taken. We used the constant comparative method to identify recurring themes within and across sites, and resolve interpretive discrepancies. KEY RESULTS: We identified three major themes related to the eConsult program: (1) eConsult increases the comprehensiveness of primary care and fills PCPs' knowledge gaps through case-based learning. (2) Factors that influence PCPs to order an eConsult rather than a traditional referral include patient preference, case complexity, and need for expert guidance. (3) Implementation challenges included increasing PCPs' awareness of the program, addressing PCPs' concerns about increased workload, recruiting engaged specialist consultants, and ensuring high quality eConsult responses. Implementation success relied on PCP ownership of the consultation process, mitigating unintended consequences, ongoing education about the program, and mechanisms for providing feedback to clinicians. CONCLUSIONS: Our findings demonstrate that an opt-in eConsult program at AMCs has the potential to increase PCP knowledge and enhance the comprehensiveness of primary care. For these benefits to be realized, program implementation requires sustained efforts to overcome barriers to use and establish norms guiding eConsult communication.