Table 2.

Facilitators to eConsult implementation using the quadruple aim framework

Provider perspective		Patient perspective	Healthcare system	Cost
PCP	Specialist
PCPs receiving timely response from specialist* ✓ A very helpful service, giving timely help and input to the front-line generalist.41	Improved communication with PCPs ✓ I think it helps in the interaction with the health care provider. They tell you what information they have, you evaluate it and then if you need further information, you tell them “This is what you need.” 30	Remote residence location* ✓ I live in a more remote location…A lot of the specialists probably aren’t going to be here, so [eConsult can] save me a trip to Ottawa.52	Increase provider knowledge capacity and confidence ✓ This information could be used to inform the planning of continuing medical education (CME) and professional development events for PCPs. 38	Developing payment models and incentives for providers to use eConsult ✓ Its success at San Francisco General Hospital depended on …and on financial incentives that were not completely wedded to clinic productivity.66
Building capacity and knowledge* ✓ Thank you to Dr. X for the excellent advice. This will also help me manage patients with similar profiles in the future.76	Educational opportunities* ✓ (eConsult) also provides education. If you take the time to write out the thinking, then they don’t have to ask you the question again because you just taught them. So it helps them be a better physician and it also will cut down on the questions.86	Timely access to specialist care ✓ If I wanted to see them [the specialist] face-to-face it would have taken possibly months.52	eConsult platform choice ✓ Innovators may be tempted to develop a service as an extension of a specific EMR program or vendor, since harnessing an existing platform can reduce the upfront time and costs associated with development. However, greater flexibility will support wider adoption, allowing the service to reach a broader segment of the population. 68	Potential cost savings for insurance payers to use eConsult ✓ Referral to specialty departments dramatically affects the annual cost of medical care for a group of insured patients. 75
	Improved referral efficiency* ✓ Satisfaction with the e-consult was high among nephrologists; in the majority of cases thought that the e-consult was efficient.87	Potential cost savings ✓ From a patient perspective, fewer office visits translates to less time taken off work and reduced transportation costs.88	eConsult ease of use ✓ The workflow of the e-consultation system must fit as seamlessly as possible into the physician’s usual workflow to ensure participation. It is important to minimize system usage time.82	Potential cost savings for society ✓ Cost savings for eConsult from the societal perspective attributable to patient avoided costs, as patients whose PCPs had originally considered a referral but ultimately chose not to refer them avoided the travel costs and lost wages/ productivity.91
	Reduced time commitments required for eConsult ✓ Reassuringly, the average self-reported time it took specialists to complete an eConsult was 11.2 min, which is shorter than it would take to complete an in-person consult.107	Acceptance of eConsult ✓ Acceptance is vital to the success of any healthcare innovation, and patients’ perspectives on new and innovative services must be thoroughly established. 68	Improved access to specialist care* ✓ The benefits include improved access to specialty care for those practicing in remote communities.67	Potential cost savings for the healthcare system ✓ Please continue with e-consult services as it will save on health [dollars] in the long run and will assist in improvement of patient care.76
	Ability to expedite face-to-face consultation if needed ✓ If we have any reservations or the patient has any reservations, we see them(face-to-face).53		Use of case manager to triage consultations ✓ Use of referral case managers to improve efficiency.51
			Security measures ✓ We reviewed our e-consult process with risk management lawyers and we were able to reassure providers that this system would not place them at undue legal risk.89
			Improved quality of care/ ‘safety net’ effect* ✓ [In] 4% of cases PCPs were not planning on sending the patient for a traditional face-to-face referral… however, the eConsultant recommended one due to the potential high-acuity nature or complexity of the problem. 38
			Organisational commitment to implementation ✓Obtaining buy-in from health system leadership is essential to lay the necessary ground work. 90
			Clarifying providers’ duty of care/role ✓ eConsults from a medical legal perspective are considered along the same lines as a “curbside consult” in that the specialist provider does assume a duty of care once the case is reviewed. 38
			End user engagement/ consultation ✓ Disseminate the benefits. (using actual data) of E-Consults for patients and for workflow to participating providers. 56
			Providing ongoing support/training ✓In contrast, a high-volume site participant noted that training was crucial. 58
			Piloting eConsult ✓I think the reason why they’ve jumped onto the bandwagon is because they probably saw how efficient it was with GI.54

✓Selected quotes supporting the theme from the literature.

*Preidentified theme (deductive).

PCP, primary care provider.