TABLE 5.

Subthemes and Illustrative Quotations for Theme 3 (Relationship Building)

Theme 3: E-consults are Widely Understood as a Factor Influencing Clinician Relationships, but Clinicians Disagree on Whether E-consults Promote or Undermine Relationship Building
Subtheme	Illustrative Quotes
Positive perception	Q15. “Going from inpatient to primary care, is <…> very lonely. … in the hospital, <…> you could page your specialist and just go find them in the hospital. <…> And so in the absence of having those relationships … the E-consult is very helpful.” (119, PCP)
	Q16. “I feel like even though it’s through the computer, it feels very collegial, which we don’t always get, because we are sort of siloed in our little world. So I think that is very nice.” (042, PCP)
	Q17. “We love working with colleagues and it’s one of the things that … I personally love about the VA, how easy it is to collaborate with other people and really have an interdisciplinary approach. And e-consults to me were just another way of doing that. <…>… what e-consults allow us to do is communicate with each other … even if we are not both available simultaneously.” (098, neurologist)
Negative perception	Q18. “Obviously, the personalization and interaction to get to know our colleagues gets compromised if all of the communication is done electronically rather than through a phone call or in person … If I were new in a place and never had the opportunity to interact with the other people who are sending e-consults, then that would certainly take away from developing relationships and collegiality …” (068, cardiologist)
	Q19. “… just everything being electronic is … making the back and forth between providers less rewarding and less familiar to people. There’s, I think, a tendency to hide a little more behind just putting it all … on the computer, and not having to have a phone conversation about what we think the real challenges are for somebody that we’re co-managing.” (018, pulmonologist)
	Q20. “I’ve been practicing medicine for a while and it’s just … gotten much less collegial. So I think that <e-consults don’t> help in that regard. … compared to 20 y ago, for example, when everything was telephonic or face-to-face, things are much less personal, much more electronic communication.” (093, pulmonologist)
	Q21. “I just think there’s a lot more conveyed on even just a five-minute phone call <than via an e-consult>. <…>… it’s a different world in the private setting. They don’t have a business without primary care. But in the academic world, whether it’s the VA or the Brigham or Mass General, it doesn’t really matter. They are plenty worked, they do plenty of research, and it’s not a priority for them to call people up and say, thank you for sending me this patient and I want to make sure you really understand my communication. So I think because of that, there’s some institutional inertia that it’s hard to overcome in terms of helping build relationships between primary care and the specialists. And if you add to that that now a significant amount of our conversations are happening by way of the computer, it just makes it that much harder.” (096, PCP)

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