TABLE 4.

Subthemes and Illustrative Quotations for Theme 2 (Iterative Communication)

Theme 2: E-consults are Perceived as an Imperfect Modality for Closed-loop Communication and/or Complex Conversations Requiring Shared Clinical Deliberation
Subtheme	Illustrative Quotes
Closed-loop communication	Q10. “… if there’s going to be a couple back-and-forths, you just need to get on an email or make a phone call and then you might document the outcome of that very succinctly in the chart …” (019, PCP)
	Q11. “If I’m recommended to order something, I have to re-consult to further ask questions if something does come back positive or concerning. So <…> I still have to close the loop, so there’s a gap.” (079, PCP)
Shared clinical deliberation	Q12. “E-consults require the person writing the consult to focus their question so that they can get a focused answer. <…> But sometimes, these questions emerge in the fog of clinical care. Which means that there are a lot of subtleties and complexities that go into these decisions. <…> And if it’s not straightforward it involves a judgement. And when it involves a judgement that is facilitated by interpersonal interactions <then> there can be as much clarity as possible. And that is hard to do in an e-consult …” (010, pulmonologist)
	Q13. “<Sometimes> it’s very clear the two people need to get on the phone or in person, right? And have a conversation. Because there’s miscommunication, it’s not clear, there’s a tone of voice. There’s all these other elements that you have to be very cautious about and very aware of.” (019, PCP)
	Q14. “… if I have a lot of uncertainty or I just need to talk through a complex case, and I feel like it involves sort of co-management with a sub-specialist that I know, then I’d much rather pick up the phone. <…> But, you know, there’s also something to say for time being important …<So I use> the e-consult for everything else that’s not a critical decision-making, that doesn’t involve like careful teamwork—you know, those can be and are probably best managed in e-consult form …” (028, PCP)

e-consult indicates electronic consultation; PCP, primary care provider.