Table 2 Main drivers, facilitators and barriers to implementation of referral, consultation and integrated eCRs and representative quotes
Drivers | Representative quotes | |
Referral systems | Enhance operational and clinical efficiency | “Specialists wanted to have all of the relevant clinical history for patients prior to a visit; productive visits are key and prior communication [wasn’t] sufficient.” |
Consultation systems and Integrated eCRs | Poor access to specialty care | “The service was developed to improve access to high-need specialties with long wait times.” |
Leakage of patients to other systems | “Drivers included coordinating and improving integration of care with the goal of retaining patients; payor data showed that approximately 30 % of patients were going outside of [organization’s name] for specialty care.” | |
Enhance care coordination and communication | “We’re trying to build good relationships with our community clinics to create an integrated safety net care system.” “I think efficiency helps the supply–demand mismatch… we have driven down the mismatch with eConsult, not by inventing new specialists, but by using our existing specialists in a better way.” | |
Facilitators | Representative quotes | |
Referral systems | Engaged executive leadership | “For our program, it was important to make eConsults/eReferrals mandatory [by the leadership]. We found that [others] that did not do this had low uptake.” |
Early clinician adopters | “Having a physician leader who was able to have dedicated time to have lots of the conversations with people, to message it, to overcome concerns and resistance, to really be the driving force behind it, I think was critical in our implementation.” | |
Consultation systems and Integrated eCRs | Provider incentives | “[Our system] is now funding reimbursement of specialists’ time for using the service.” |
User-friendly technology | “The template was easy to build and make friendly for staff and the doctors.” | |
Platform integrated into electronic medical record | “We have a platform available within our electronic health record program that we were able to adapt to our need/s.” | |
Barriers | Representative quotes | |
Referral systems | Provider resistance to change workflows | “As you well know, unless you can mandate, it is very difficult to get PCPs to adapt if they view this as taking any more time.” |
Lack of eCR integration into electronic medical record | “With no shared [technology], it has been difficult to get providers to [move past the workflow issues] and see the benefit of … improved integration of care.” | |
Consultation systems or integrated eCRs | Primary care provider resistance to change in workflows | “Many physicians didn’t want to submit [the referral] themselves.” |
Lack of reimbursement mechanisms | “The biggest barrier to adoption we faced was reimbursement. … It is this funding issue that is preventing expansion of the program to include additional specialties.” “In order to support adoption of the electronic consult system, we obtained grant funding. We are currently using the results … to build a case for the state reimbursing electronic referrals.” | |
Specialist provider liability concerns | “When we implemented … we got quite a lot – not surprising, but consistent – feedback or questions or skepticism from specialists with the liability, specialist skepticism about whether the PCP [would] be able to provide reliable information.” | |