eConsultation for Deprescribing Among Older Adults: Clinician Perspectives on Implementation Barriers and Facilitators

Abstract

Background

Electronic consultations (eConsults) enable asynchronous consultation between primary care providers (PCPs) and specialists. eConsults have been used successfully to manage a variety of conditions and have the potential to help PCPs manage polypharmacy and promote deprescribing.

Objective

To elicit clinician perspectives on barriers/facilitators of using eConsults for deprescribing among older adults within a university health network.

Design

Semi-structured interviews.

Participants

PCPs, geriatricians, and pharmacists.

Approach

We used the COM-B (Capability, Opportunity, Motivation, and Behavior) model to structure the interview guide and qualitative analysis methods to identify barriers/facilitators of (1) deprescribing and (2) use of eConsults for deprescribing.

Key Results

Of 28 participants, 19 were PCPs (13 physicians, 4 residents, 2 nurse practitioners), 7 were geriatricians, and 2 were pharmacists. Barriers and facilitators to deprescribing: PCPs considered deprescribing important but identified myriad barriers (e.g., time constraints, fragmented clinical care, lack of pharmacist integration, and patient/family resistance). Use of eConsults for deprescribing: Both PCPs and geriatricians highlighted the limits of contextual information available through electronic health record (vs. face-to-face) to render specific and actionable eConsults (e.g., knowledge of prior deprescribing attempts). Participants from all groups expressed interest in a targeted process whereby eConsults could be offered for select patients based on key factors (e.g., polypharmacy or certain comorbidities) and accepted or declined by PCPs, with pithy recommendations delivered in a timely manner relative to patient appointments. This was encapsulated by one PCP: “they need to be crisp and to the point to be helpful, with specific suggestions of something that could be discontinued or switched…not, ‘hey, did you know your patient is on over 12 medicines?’”.

Conclusions

Clinicians identified multifaceted factors influencing the utility of eConsults for deprescribing among older adults in primary care. Deprescribing eConsult interventions should be timely, actionable, and mindful of limitations of electronic chart review.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-024-08899-0.

INTRODUCTION

Polypharmacy among older adults is highly prevalent, with over two-thirds of older adults in the USA taking five or more medications or supplements, and has increased in recent decades.¹ Although many medications prescribed to older patients may be guideline-concordant, some medications have limited value, are discordant with goals of care, and are associated with more harm than benefit.² Polypharmacy is associated with adverse consequences for older adults, including drug reactions and significant morbidity such as falls and cognitive decline.^3,4

An essential component of addressing polypharmacy among older adult patients is deprescribing, the clinically supervised process of tapering drugs with the goal of minimizing inappropriate polypharmacy and improving patient outcomes.^2,5,6 Evidence supports the feasibility, safety, and benefits of deprescribing interventions across medication classes, interventions, and settings.^7–9 Nevertheless, addressing polypharmacy through deprescribing in practice remains a vexing challenge.^10,11

One healthcare innovation that holds promise for achieving deprescribing in clinical practice is electronic consultation (eConsult). eConsults allow for asynchronous consultation between clinicians—typically between primary care providers (PCPs) who may request eConsults for their patients and specialists who review the electronic health record (EHR) and provide recommendations. eConsults have been deployed by health systems to increase access to subspecialty care,^12,13 manage various medical conditions, and provide educational benefit to PCPs.^14,15 Prior Veterans Health Administration (VHA)–based work has explored the utility of pulmonologist-initiated eConsults aiming to deprescribe guideline-discordant inhaled corticosteroid prescriptions in veterans with chronic obstructive pulmonary disease (COPD). A central finding was that patients were receptive to medication changes suggested through the eConsults.^16,17 Given a shortage of specialists with training in geriatrics,¹⁸ eConsults linking PCPs to geriatric specialists could help PCPs manage polypharmacy and promote deprescribing among older adult patients.^19–21 However, a remaining gap in prior literature is PCPs’ and specialists’ perceptions of the potential utility of eConsults for enabling deprescribing for their older adult patients and how deprescribing eConsults could be most effectively deployed for this purpose, especially in non-VHA settings.

We conducted a study to address this evidence gap and to provide formative data for deprescribing eConsult intervention development in one healthcare system. We aimed to build on qualitative work by others regarding perspectives on deprescribing in primary care and on the implementation of eConsult programs, and to explore the intersection of these topics.^{16,17,22–27} We additionally explored perspectives on potential options for integrating deprescribing eConsults into practice, including PCP-initiated (i.e., PCP initiates eConsult referral in lieu of a referral for a face-to-face visit), targeted (i.e., suggestion to consider an eConsult is generated based on patient factors), or automated mechanisms (i.e., eConsults are completed automatically on select patients).^15,28–30

METHODS

Design, Setting, and Participants

From November 2022 to November 2023, we conducted semi-structured interviews to elicit clinician perspectives on barriers/facilitators of using eConsults to promote deprescribing among older adults in primary care settings within the University of California, San Francisco health system. The system’s eConsult program was established in 2012, includes over 30 specialties, and facilitates approximately 6000 eConsults annually.³¹ At the start of our data collection period, the eConsult program was funded internally by the health system (with direct payments to participating specialists), as eConsults were not reimbursable under fee-for-service payments; partway through data collection (July 2023), the system adopted a process whereby insurance was billed for eConsults, requiring eConsult users to obtain patient consent.²⁸

We recruited participants from three primary care practices, the Division of Geriatrics, and the School of Pharmacy. To support program development, we sampled from both potential users of the eConsult and consultants who would be tasked with staffing and completing eConsults. Thus, eligible participants were (1) potential users: practicing PCPs including physicians (faculty and resident trainees) and nurse practitioners from Internal Medicine and Family Medicine practices and (2) potential consultants: geriatricians and clinical pharmacists providing consultative services.

The Institutional Review Board of the University of California, San Francisco approved this research. We followed the consolidated criteria for reporting qualitative research (COREQ, Appendix A online).³²

Data Collection

The lead author (MEG) conducted interviews lasting approximately 45 min and recorded with consent of participants. We conducted interviews until emergent themes were redundant of previously collected data, suggesting thematic data saturation.^33,34

Our interview guides were informed by the Capability, Opportunity, Motivation, and Behavior (COM-B) model (Appendix B online).^35,36 Capability refers to an individual’s psychological and physical capability to engage in a behavior (e.g., knowledge and skills); opportunity refers to physical and social environmental factors that enable or prompt a behavior; and motivation refers to processes that direct behavior including habitual or cognitive processes, emotional responses, goals, and beliefs.

Because the planned eConsult intervention was focused on promoting deprescribing in primary care, we first assessed barriers and facilitators to the general process of deprescribing by PCPs. We then presented interviewees with potential program options for integrating deprescribing eConsults into primary care practice (PCP-initiated, targeted, and automated).

We collected descriptive measures including self-reported age, sex, race/ethnicity, position, and years of practice. Participants received a $50 gift card for their participation.

Data Management and Analysis

We followed Hamilton’s approach to implementation science analysis (Appendix A online).^37–39 First, we created an analytic matrix template organized by COM-B interview domains³⁵ and two interrelated clinician behaviors: (1) general deprescribing practices and (2) use of eConsults for deprescribing. The lead author coded participant interview data into this matrix, referencing field notes and audio recordings as needed, and inductively coding emergent themes within deductive categories. One coauthor (MH) reviewed field notes and coding from the lead author; other team members (LJH, KLH) reviewed emerging codes/themes. Coauthors used regular meetings to adjudicate coding discrepancies and refine relationships between codes and summary themes. We integrated recommendations for deprescribing eConsult program development from participants with key insights from prior studies.

RESULTS

Sample Description

We recruited 47 participants; 28 (60%) agreed to participate. Nineteen were PCPs (13 physicians from Internal Medicine or Family Medicine practices, 4 residents, and 2 nurse practitioners), 7 were geriatricians, and 2 were pharmacists. One participant opted not to provide responses to demographic questions. Of those who did, 18 (64%) self-identified as female. Seven individuals (25%) self-identified as Asian, one (4%) as Black, one (4%) as multiracial, and 2 (7%) as Hispanic. On average, participants had practiced for 15 years and devoted half of their effort to direct clinical care. Twenty-one interviews (75%) were completed prior to the health system’s adoption of insurance billing for eConsults.

We present findings and representative quotations regarding (1) deprescribing among older adult patients in primary care settings and (2) potential use of eConsults for deprescribing. Figure 1 highlights key findings, conceptualized in two rings. At the center is the goal behavior of PCP and eConsultant engagement in a potential deprescribing eConsult program. While PCPs are the principal users of eConsults, we corroborated and supplemented PCP perspectives through geriatrician and pharmacist interviews and included these consultants as agents in the deprescribing intervention (i.e., eConsultants). The outer ring (barriers/facilitators of deprescribing) provides context for the central ring (barriers/facilitators of eConsult use for deprescribing).

Figure 1.

Key findings concerning barriers/facilitators of deprescribing in primary care settings (outer ring) and potential use of eConsults for deprescribing (inner ring). Legend: The figure summarizes qualitative findings regarding deprescribing in primary care settings and potential use of eConsults for deprescribing. The goal behavior of PCPs and eConsultants engaging in a deprescribing eConsult program is highlighted in the central blue circle; facilitators are depicted with + and in green color in the top half and barriers are depicted with – and in red color in the bottom half. We present facilitators and barriers across COM-B categories of (1) the outer ring: deprescribing among older adults in primary care settings and (2) the inner ring: using eConsults to promote deprescribing.

Overarching Perspectives Regarding Deprescribing for Older Adults in Primary Care (Outer Ring of Fig. 1)

Facilitators

Capacity Facilitators

Many PCPs endorsed having a well-defined awareness of the importance of deprescribing; this awareness facilitated their ability to deprescribe and was augmented by access to easy-to-follow resources to guide deprescribing. They described deprescribing as an important aspect of optimizing medications with an eye to thinking about “the potential benefit of therapy versus potential for harm and then weighing that risk over either the susceptibility of the patient population or the duration of time over which a harm or benefit could potentially be seen” and “feasibility from the patient end” (PCP_11).

Opportunity Facilitators

Factors included what some PCPs characterized as a health system culture that was “extremely collaborative and generally respectful toward PCPs,” in which specialists will often check in regarding prescribing a medication for mutual patients (PCP_5). Longitudinal relationships between PCPs and their patients also increased opportunity for deprescribing.

Motivation Facilitators

Many PCPs endorsed viewing deprescribing as part of their clinical purview in caring for older adults as a key motivating factor. Several also offered that prior positive experiences with deprescribing further motivated the practice.

Barriers

Capacity Barriers

While PCPs endorsed a well-defined notion of deprescribing (described above), many nevertheless desired an “algorithm” or “checklist” for approaching deprescribing (PCP_4) as well as knowledge of the evidence base for deprescribing, feeling these were lacking in their clinical training and practice.

Opportunity Barriers

Most barriers to deprescribing in clinical practice related to the opportunity category, specifically environmental barriers. Paramount among these was time constraint, particularly within a system lacking financial incentives for deprescribing. All groups voiced this concern: “the most efficient thing to do is just hit refill. Every time you want to stop something, from a time or RVU standpoint, those incentives to us, deprescribing is more time and work than hitting refill…because for most patients, deprescribing means a conversation that will slow your visit down” (PCP_5). Other environmental barriers included fragmented care identified by PCPs and geriatricians (e.g., patients seeing multiple clinicians due to scheduling issues) and inadequate access to clinical pharmacists to help with medication reconciliation and medication-related queries. Participants from all groups emphasized the onerous process of medication reconciliation within a fragmented system as a critical barrier. For example, one PCP described reconciling medications from outside the health system: “It is such a mess. You may find meds that are out of date. If you open that door, it will take forever, so I don’t want to walk into that door, even though I wonder about it” (PCP_17). Additional barriers stemmed from the influence of others. Several PCPs endorsed challenges deprescribing for patients managed by specialists who are “resistant to deprescribing” (PCP_19) or when patients and/or care partners were hesitant to stop a long-term medication (particularly when they were otherwise feeling healthy).

Motivation Barriers

Contrary to the overall positive impression of deprescribing expressed by most PCPs, a few PCPs cited specific cases in which they had “bad experiences with deprescribing” when patients had return of their previously treated symptom or worsening disease control with prior deprescribing attempts (PCP_3).

Potential Use of eConsults for Deprescribing (Inner Ring of Fig. 1)

Facilitators

Capability Facilitators

Participants from all groups unanimously expressed the importance of promoting the availability of eConsults to assist with deprescribing and management of polypharmacy among older adult patients. Without a concerted effort to educate providers regarding the potential use of eConsults to help with the management of polypharmacy, PCPs and pharmacists felt that such initiatives were unlikely to be successful.

Opportunity Facilitators

Participants thought that appropriately targeted eConsults (i.e., pertaining to patients in whom deprescribing recommendations would be helpful and relevant) would facilitate deprescribing. First, PCPs were widely supportive of a “nudge” to consider requesting a deprescribing eConsult (PCP_13) for relevant patients, given that polypharmacy was often an overlooked problem. PCPs varied in terms of favored mechanisms for delivering targeted eConsults. Many PCPs were enthusiastic about an opt-in option, where a suggestion to order an eConsult on relevant patients could be accepted/declined by the PCP, or an opt-out option where PCPs were notified of a planned eConsult and could decline. A smaller number expressed interest in automatically completed eConsults—entirely without PCP input—to raise awareness around deprescribing opportunities. In general, PCPs with fewer years of experience and nurse practitioners expressed more enthusiasm about opt-out and/or automated options, compared to more experienced PCPs. However, individual providers recognized that other providers would vary in their preferences, as one PCP commented regarding opt-in or opt-out options:

I like both of those potential options…I do like the opt-out by default rather than opt-in. That would be my personal style…I can see how some providers would want to have a more firm grasp over whether that process were to unfold…but I would feel very comfortable with by default this process, on my panel, certain patients get identified, I get notified…‘this is somebody who would benefit from this, we’re going to proceed with this eConsult unless you’d like us not to.’ I would find that very useful. (PCP_11)

Second, PCPs, geriatricians, and pharmacists stated that deprescribing recommendations would best be delivered “in the context of an upcoming visit rather than just randomly” (PCP_1) to time delivery “so they actually utilize it and have not forgotten about it” (Geri_6). Third, many participants called for “triaging which patients would benefit the most from a geriatrician” (Geri_5), tailoring interventions to those patients for whom recommendations would be particularly helpful. Commonly endorsed conditions (by both PCPs and geriatricians) that could prompt targeted eConsults were geriatric syndromes including polypharmacy, falls, cognitive impairment, or recent hospitalizations. PCPs often cited psychotropic medications as high priority for assistance. Appropriately targeted deprescribing eConsults were viewed as an essential means to avoid being “flooded” with unsolicited information (PCP_18).

Motivation Facilitators

Participants described several motivation-related facilitators using eConsults for deprescribing. Given substantial time constraints, PCPs were unanimous in their desire for eConsult deprescribing recommendations to be pithy and actionable: “they need to be crisp and to the point to be helpful, with specific suggestions of something that could be discontinued or switched…not, ‘hey, did you know your patient is on over 12 medicines?’” (PCP_18). PCPs emphasized connecting recommendations to evidence, offering alternatives to manage the condition for which a targeted medication was prescribed, and adopting a nonjudgmental tone to respect PCP autonomy (e.g., acknowledging that exceptions may exist to any recommendation generated from chart review). These increased the likelihood that such eConsult recommendations would be useful and not viewed as boilerplate language. PCPs, geriatricians, and pharmacists referenced specific content that would be potentially useful in eConsults. This included (1) prioritizing which medications would be most important to target for deprescribing and in what order; (2) conveying specific instructions for tapering as well as signs and symptoms of adverse drug withdrawal to watch for; (3) providing language-concordant patient-facing materials regarding deprescribing of specific medications that could be given to the patient during the visit; and (4) suggesting language to guide deprescribing conversations.

Several PCPs felt that if a medication was listed on the active medications list in the electronic health record (EHR), it was reliable enough to form the basis of targeted outreach. Participants from all groups highlighted the importance of aligning targeted eConsults with larger incentives within clinical practice (e.g., system-wide efforts to reduce chronic opioid prescribing).

Barriers

Capability Barriers

Regarding PCP-initiated eConsults, PCPs identified a steep capability-related barrier in not knowing “what geriatrics can offer in the eConsult,” and a desire for “being very explicit about what geriatrics can do” (PCP_2) with an eConsult. Most signaled that they rarely initiated eConsults to geriatrics; in contrast, they frequently initiated eConsults to other services, such as hematology.

Opportunity Barriers

As eConsults are based on chart review (as opposed to a face-to-face visit), participants from all groups raised multiple concerns related to opportunity. First, some providers voiced concern that relying on EHR review alone could lessen the potential impact of deprescribing-related eConsults, as key contextual information may be missing that would be important to shaping tailored recommendations: “You don’t want your eConsult to be what you could have gotten by going on UpToDate or what looks like a series of dot phrases. You feel, I could have gone and looked it up…How does it really become personal to that patient?” (PCP_18). Similarly, geriatricians worried that the value of some deprescribing recommendations would be undermined by contextual information potentially missing from chart review:

You can see the most recent fill list, no idea if patient is taking it though…The family will tell me, ‘oh, they only take that once a month, or they stopped taking that because of XYZ side effects.’ So, it’s not an issue because they aren’t taking it anyway. Or, what I would have recommended they have already tried but there is no record of that in the chart, and they didn’t like the side effects or it didn’t work for them. (Geri_6).

Finally, both PCPs and geriatricians were concerned about the large amount of time that chart review could require for the eConsultant. One geriatrician stated, “like any chart review when you’re getting to know a patient, you have a lot of constraints usually. So, you’re going to dig where you think you need to dig…When I get the chart, I do remember contemplating that, ‘how deep do I need to go?’” (Geri_7).

During data collection, health system billing procedures changed such that eConsults were billed to insurance and providers were newly required to obtain patient consent to eConsult prior to initiating an eConsult. Several subsequently interviewed participants flagged this additional step as a potential barrier—particularly for targeted or automated eConsults—and stressed the importance of ensuring that patients did not receive unexpected bills.

Motivation Barriers

Participants elucidated key motivation-related barriers to use of eConsults for deprescribing. Chief among these was the concern by some that deprescribing eConsult recommendations could be perceived as unhelpful and off-putting if delivered in an unsolicited manner:

I’ll give you an example of what you don’t want to become. Various pharmacies and pharmaceutical benefit plans and HMOs—I don’t know who is doing it—I get these faxed things that are not from within [our] system saying things like, ‘your patient has been on a PPI for over 6 months, consider taking it off.’ As a rule, I do not read those. I throw them directly in the recycling bin, and I am vaguely resentful that somebody thinks that I really want their unsolicited input into the care of my patients. (PCP_18).

An area of particularly strong consensus between PCPs, geriatricians, and pharmacists was recognition that targeted eConsults would likely increase PCPs’ workloads, particularly given that within the traditional eConsult model, the work of deprescribing (i.e., following through with recommendations) would fall to PCPs. One pharmacist summed this up, asking “Who’s going to do the action?” and worrying that eConsults could signal, “here are all these problems for [PCPs] to work on” (Pharm_2). Multiple geriatricians and pharmacists spontaneously raised this concern about their PCP colleagues, recognizing the high levels of burnout and stress in primary care. Geriatricians highlighted an additional motivation-related barrier when medication regimens were not perceived as potentially harmful: “My first thought is if I were the PCP, ‘what’s in it for me?’ Because you may increase my time, and no one has a problem with the way things are right now…A lot of these are theoretical risks that may or may not happen…or they haven’t gotten in trouble so far” (Geri_7). Finally, several PCPs raised concerns about potential medicolegal consequences with automated eConsults. If an unsolicited note were placed in the chart recommending cessation of a given medication, “it is now more awkward…you do feel like you have to justify it more in case something ever happens to the patient. Now an expert has recommended that I stop that medication…now I really feel like I have to document” (PCP_15).

Recommendations

Participants provided recommendations for the development of deprescribing eConsult programs. We synthesized their perspectives and key recommendations from other eConsult literature in Table 1 and a mock-up of a hypothetical deprescribing eConsult (Fig. 2).

Table 1.

Recommendations for Deprescribing-Related eConsult Intervention Development, Supported by Study Interviews (Not Cited) and Related Literature (Cited)

	Selected themes from study		Program recommendations
Capability	Facilitators	Awareness of deprescribing eConsult availability (whether PCP-initiated, targeted, or automated)	(1) Identify specialist/eConsultant champion (e.g., specialist geriatrician who is known to PCPs; leading co-management conferences related to deprescribing23 in addition to staffing eConsults) (2) Create eConsult newsletters, sent periodically to participating PCPs/practices, to promote helpful exemplars of eConsult responses23
	Barriers	Lack of knowledge about deprescribing eConsult
Opportunity	Facilitators	Appropriate nudges to consider eConsult Targeted eConsults that are timely and adapted to high-yield patients (e.g., experiencing falls)	(1) Embed alerts in EHR to consider eConsults for select patients aligned with clinic incentives and geriatric syndromes (e.g., above a certain threshold of polypharmacy or in setting of high fall risk19) (2) Consider offering opt-out (whereby PCP receives notification of planned eConsult and can decline) or opt-in (whereby PCP receives a suggestion to consider eConsult and can accept/decline) targeted eConsults (3) Deliver information within one week (or shorter) of upcoming primary care appointment for targeted eConsults (4) Standardize customizable templates to facilitate EHR review and organize recommendations15
	Barriers	Lack of contextual information in chart review Time intensity (for eConsultant)
Motivation	Facilitators	Tailored, brief, useful content in eConsult Nonjudgmental tone Reliable EHR active medication list	(1) Use eConsult to prioritize which medications to target (among many); convey relevant literature (both around deprescribing and/or potential harms of specific medications); provide resources regarding approaches to deprescribing and tapering strategies (if relevant). Include curated language-concordant patient-facing materials (such as those available at www.deprescribing.org) and suggested language for communication of recommendations47 (2) Standardize eConsult wording to a nonjudgmental tone, respectful of PCP autonomy, and that acknowledges the limits of chart review (3) Improve medication reconciliation processes to ensure accuracy of documented medication lists (4) Extend eConsult model beyond asynchronous knowledge transfer (e.g., incorporation of eConsults into a broader intervention including a multidisciplinary team that can follow-up directly with patient/family regarding recommendations,19,30,41 remove workload from PCP,12 perform best-possible medication history,20,21 follow for potential adverse drug withdrawal events19)
	Barriers	Unsolicited input/work Galvanizing deprescribing when medication regimens are not perceived as potentially harmful

Figure 2.

Mock-up of a hypothetical deprescribing eConsult, incorporating study findings. Legend: The left panel depicts a mock-up of a hypothetical deprescribing eConsult involving a fictitious case. The right panel (blue background) highlights key components of the hypothetical deprescribing eConsult, which arose from study interviews and recommendations from the literature.

DISCUSSION

In this study, PCPs, geriatricians, and clinical pharmacists identified barriers and facilitators to (1) deprescribing medications among older adults in primary care and (2) the potential use of eConsults to promote deprescribing. PCPs considered deprescribing to be within the PCP’s purview and an important component of addressing polypharmacy for older adults. However, they were hindered by severe time constraints, fragmented systems, and lack of systematic approaches to deprescribing. Within this context, they articulated specific circumstances under which it would be feasible and acceptable to implement a successful deprescribing eConsult program. These included emphasizing the importance of promoting the availability of eConsults to aid with deprescribing; consideration to appropriate EHR nudges to facilitate eConsults and to target eConsults based on key patient characteristics; and the delivery, via eConsults, of tailored, brief, and actionable content in a nonjudgmental manner respectful of PCP autonomy.

Our work validates barriers and facilitators to deprescribing medications in primary care settings detailed in prior studies and systematic reviews.^22,26,27,40 A 2020 review²² of barriers and facilitators to deprescribing in primary care presented findings within a social-ecological model. While we organized results within the COM-B framework, our key findings regarding the process of deprescribing similarly span individual (e.g., patient/family perspectives on deprescribing); interpersonal (e.g., fragmented care); organizational (e.g., limited time); cultural (e.g., lack of financial incentives) levels. Broader barriers/facilitators of deprescribing reflect the multilayered nature of deprescribing in primary care and provide crucial context for evaluating solutions, such as eConsultation.

Findings regarding the potential use of eConsults to facilitate deprescribing expand a sparse literature and underscore that eConsults may be an important part of multicomponent interventions to support deprescribing in primary care settings. Programs utilizing eConsults to facilitate deprescribing specifically among older adults have been developed, but these incorporated specialist EHR case review as part of a broader suite of supportive actions to facilitate deprescribing.^19,21 For example, a VHA deprescribing program for older veterans at risk for falls utilized central case finding, electronic case reviews, and conveyance of deprescribing recommendations to PCPs; a pilot study supported the intervention’s acceptability to prescribers and patients and potential to reduce drug-related falls.¹⁹ The intervention included interactions between specialists and patients in telephone calls reviewing recommendations, assessing adherence, and monitoring for adverse effects. By contrast, we examined perspectives on eConsults as a single intervention to promote deprescribing. Our participants were wary that unsolicited deprescribing eConsults ran the risk of creating extra work for PCPs; several recommended incorporating eConsults into larger processes to unburden PCPs (e.g., multidisciplinary team to enact/follow-up on recommendations). VHA programs have deployed specialist-initiated eConsults to optimize care^41,42 and deprescribe guideline-discordant inhaled corticosteroids^16,17 among veterans with COPD. Qualitative analyses revealed similar themes to the present study including the centrality of PCP–specialist relationships, the challenge of overcoming clinical inertia, and the importance of honoring PCP autonomy and time constraints.^16,41 Since VHA-specific findings may not apply to non-VHA health systems, our results therefore extend prior work into other healthcare systems.

Several considerations warrant further discussion. First, interviews explored various formats for deprescribing eConsults. Many PCPs expressed enthusiasm for targeted approaches, in which selected patients would be flagged for eConsult consideration based on key clinical factors. This finding dovetails with prior work on eConsult interventions seeking to increase specialist input into patient care, where findings emphasized supporting PCP autonomy and minimizing additional workload.^12,27,41,43 Targeted, automated eConsult programs in inpatient settings are popular with clinicians.^28,29,44,45 It is possible that we found automated eConsults to be less palatable in the primary care setting given other constraints described by participants, including PCPs’ longitudinal interactions with patients, time constraints, and limitations of ascertaining contextual information from EHR review. Second, during data collection, our health system adopted a process whereby insurance was billed for eConsults.^28,46 While billing may help sustain eConsult interventions, obtaining patient consent potentially creates more work for PCPs. Furthermore, this finding was not present in previously mentioned VHA work involving specialist-initiated eConsults, emphasizing the importance of adapting eConsult programs to health system organization and financing.¹⁷

Limitations of the study include conducting interviews within an academic medical center with a well-established multispecialty eConsult program. Findings may not be transferrable to non-academic settings or those in which eConsults are less established. While most recruited individuals participated, it is possible that non-responders may have responded differently. Finally, our sampling strategy does not enable a formal comparative analysis between PCPs, geriatricians, and pharmacists. However, we noted a high degree of agreement between professionals across many themes—especially around a desire to design solutions that are respectful of PCP workloads.

In summary, deprescribing for older adults is generally viewed as an important aspect of managing polypharmacy, but PCPs experience myriad barriers to deprescribing. eConsults represent a potential innovation for addressing barriers and fostering successful deprescribing with older adults in primary care. To ensure successful implementation of deprescribing eConsults, programs should consider targeting eConsults based on key clinical characteristics, conveying actionable and timely recommendations, minimizing workload additions, and incorporating eConsults into broader programs involving patient engagement and follow-up.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution:

Matthew E. Growdon had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Growdon, Karliner, Gonzales, Steinman, and Harrison. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Growdon. Critical revision of the manuscript for important intellectual content: All authors. Qualitative analysis: Growdon, Hunt, Miller, Halim, Steinman, and Harrison. Obtained funding: Growdon. Administrative, technical, or material support: Growdon, Steinman, and Harrison. Study supervision: Harrison.

Funding

The following authors were supported by the National Institute on Aging (NIA): Dr. Growdon (R03AG078804, P30AG044281), Dr. Hunt (K76AG074924), Dr. Miller (P30AG044281), Dr. Karliner (K24AG067003), Dr. Sudore (K24AG054415), Dr. Steinman (P30AG044281, 1R24AG064025, K24AG049057), and Dr. Harrison (P30AG044281). The following authors were supported by AHRQ: Dr. Growdon (K12HS026383) and Dr. Gonzales (K12HS026383, P30HS029738). The following authors were supported by NCATS: Dr. Miller (KL2TR001870) and Dr. Gonzales (UL1 TR991872). Dr. Gonzales was additionally supported by NHLBI (R61HL157804) and PCORI (A141833).

Declarations:

Conflict of Interest:

The authors have declared no conflicts of interest for this article. Dr. Steinman reports receiving royalties from UpToDate and honoraria from the American Geriatrics Society outside of this work.