Table 1.

Barriers to eConsult implementation using the quadruple aim framework

Provider perspective		Patient perspective	Healthcare system	Cost
PCP	Specialist
Increased workload and workflow disruptions* ✗ It was a lot easier and quicker for me to write a consultation on…paper…Now I’m having to go through a longer process with a few more hurdles in it 54	Increased workload * ✗ Specialists also experienced greater workload in the form of pre-consultative exchange and virtual management, which also served as a barrier to implementation 16	Some patients preference to see specialists face-to-face ✗ It’s important to see the specialist to feel more secure.59	eConsult system design challenges* ✗ To find an application able to integrate seamlessly with diverse systems is often challenging 82	Insufficient remuneration for providers* ✗ A key barrier to widespread adoption of preconsultation exchange is the development of reimbursement models 77
Technical challenges to use eConsult* ✗ When I added a follow up question it never seems to go through and the consult disappeared. I had to request a new consult with my follow up question.76	Concerns with liability ✗ Another challenge unique to electronic consultation and integrated eCR [eConsult] systems but not referral systems was specialist concern about liability 78	Perceived decrease in accessibility to specialist care* ✗ And if I feel like my doctor is brushing off that information, is not communicating other symptoms 48	Lack of resources* ✗ Health systems or practices initiating telehealth programs need to provide a base investment in the technology and then provide an ongoing and available infrastructure 67	Provider payment structure (salaried physicians vs fee-for-service models) ✗ And might only be cost-effective in a non -fee-for-service model such as one found in the VHA [Veterans Health Administration] 83
Loss of specialist contact ✗ PCP concerns included…unable to select the specific consultant 15	Loss of patient contact ✗ A minority of them prefer not to use VCs [virtual consults] because of…discomfort with an impersonal process 79	Concerns about safety/ appropriateness of eConsult ✗ I asked someone [a specialist] and he told me to give you this. If something happens to you, it’s not my responsibility because the other doctor prescribed it 48	Variation in licensure requirements across provinces/states ✗ In fact, licensure requirements also differ from state to state, and this introduces a significant possible variation in practice 67
Unfamiliarity with using eConsult service ✗ The preparation…what kinds of tests have to be done.53	Challenges with the quality/content of eConsult ✗ Referrals that lack a clear consultative question and relevant clinical data often render a specialist unable to make a clear diagnosis or a fully developed management plan 80		Privacy concerns* ✗ Concerns over privacy remain a barrier to the adoption of electronic platforms or innovations among health care providers 59
Insufficient remuneration to use eConsult ✗ Lack of reimbursement for PCP to submit the consultation request electronically 44	Challenges with the use of technology ✗ However, until a more slim-line IT system is developed reducing the number of steps involved in completing an eC (electronic consultation), …it appears to be beneficial for all parties except secondary care 81
Challenges related to patient follow-up ✗ Concern about how and when to communicate with patients regarding a consultant’s recommendations 55	Insufficient remuneration to use eConsult ✗ Concerns included… the need for adequate protected time and credit 15
Receiving timely responses from specialists ✗ PCPs were not satisfied with the depth of the answer that was provided 76

✗Selected quotes supporting the theme from the literature.

*Preidentified theme (deductive).

PCP, primary care provider.