Table 3.

Representative quotations about key aspects of specialty care coordination

PCPs and Endocrinologist Perspectives
Clarity and agreement on clinician roles and responsibilities are fundamental	“Typically you assume that the person writing the note is responsible for the action item but what we found is that's not consistently the case…we’ve had no end of trouble with assuming that one side or the other is coordinating a test, study, or patient communication…”(PCP 12)
	“Most critical is closed-loop communication between the consulting service and the primary care provider in a consistent and reliable fashion followed with clear expectations around new patients and identifying who owns which piece of chronic care management or diagnostic management. There are too many dropped balls otherwise…It just creates an imperative to have clear and transparent communication about roles and responsibilities.” (Endocrinologist 4)
Limitations to coordination through the shared electronic medical record	“If I have a patient who is complicated there’s really no way I can summarize those nuances in a consult request and the patient can’t tell the story and there’s no way you’ll get it from the chart except by looking through years of notes. There’s just no way to effectively get the information across in the chart.” (PCP 6)
	“I think [it] was intended that the primary care physician would utilize the specialty providers to address [the uploaded blood sugars] but it’s never been laid out so explicitly, and what usually happens is nothing. This mass of data bombards the PCPs and few treatment decisions are made…VERY occasionally that information is forwarded to [me] with no inquiry as to whether we recommend any action. There's a transfer of information but there's no coordination.” (Endocrinologist 2)
Direct communication and strong clinician relationships help overcome EMR limitations	“If the question’s not worth a full consult I’d love to be able to just call real quick, but I don’t know who they are or how to reach them…it's not knowing physically where they are, not wanting to have to page them and wait for a call back, not being able to pick up a phone and get to them directly.” (PCP 1)
	“I know who most of the endocrinologists are. I've worked with them a long time so I'll just call them. Not everybody does that or feels comfortable or even knows who these people are. But I'd rather get it done right now than send a love letter and hope they get back to me….and you know, it's hard to be rude to someone that you know, right?” (PCP 11)
Patient Perspectives
Specialty care coordination occurs at multiple levels	“Coordinated care? That means everything is working…all my medications are arriving, all my questions are being answered, and I'm doing what I'm supposed to do.” (Focus Group 1)
	“I've got a voice that I speak to named [X] and she is absolutely super. She contacts the primary care doctor and my diabetes doctor…she does my prescription order and all that. I take twenty-one pills a day…but I don't even think about it…it's like your guardian angel. She's a registered nurse. She knows everything there is to know actually.” (Focus Group 2)
Who is primarily responsible for coordination of specialty care?	“They do an excellent job but it's getting to the right person and sometimes there’s a delay. But at the same time the ultimate responsibility for my healthcare lies with me” (Focus Group 2)
	“I have obviously got a problem with my diabetes but I have not had a blood test done in six months. I don't have doctor's appointments. I call up to make a diabetes specialist appointment and my appointments are three or four months out …I have nobody to call and don’t know who can help me. Now I understand that I could be more proactive and I could force the issue but what I don't understand is why do I have to maintain everything about me when it comes to their appointments? How do I even do that?” (Focus Group 1)