Implementing an Opt-in eConsult Program at Seven Academic Medical Centers: a Qualitative Analysis of Primary Care Provider Experiences

  • Stefanie A. DeedsEmail author
  • Kimberly J. Dowdell
  • Lisa D. Chew
  • Sara L. Ackerman
Original Research



Electronic consultation (eConsult), which involves primary care provider (PCP)-to-specialist asynchronous consultation, is increasingly used in health care systems to streamline care and to improve patient access. The Association of American Medical Colleges (AAMC) formed a collaborative to support the implementation of an electronic medical record (EMR)-based, opt-in eConsult program across multiple academic medical centers (AMCs). In this model, PCPs can elect to send either an eConsult or a traditional referral.


We sought to understand the PCP experience with eConsult to identify facilitators of and barriers to the successful adoption of the model.

Design and Participants

We conducted 35 semi-structured interviews and 6 focus groups with a range of primary care providers at 7 AMCs participating in the AAMC collaborative.


Interviews were recorded and transcribed or detailed field notes were taken. We used the constant comparative method to identify recurring themes within and across sites, and resolve interpretive discrepancies.

Key Results

We identified three major themes related to the eConsult program: (1) eConsult increases the comprehensiveness of primary care and fills PCPs’ knowledge gaps through case-based learning. (2) Factors that influence PCPs to order an eConsult rather than a traditional referral include patient preference, case complexity, and need for expert guidance. (3) Implementation challenges included increasing PCPs’ awareness of the program, addressing PCPs’ concerns about increased workload, recruiting engaged specialist consultants, and ensuring high quality eConsult responses. Implementation success relied on PCP ownership of the consultation process, mitigating unintended consequences, ongoing education about the program, and mechanisms for providing feedback to clinicians.


Our findings demonstrate that an opt-in eConsult program at AMCs has the potential to increase PCP knowledge and enhance the comprehensiveness of primary care. For these benefits to be realized, program implementation requires sustained efforts to overcome barriers to use and establish norms guiding eConsult communication.


eConsults primary care consultation academic medical center health care delivery 



The authors would like to thank Nat Gleason, Scott Shipman, Meaghan Quinn, Sarah Hampton, Gina Intinarelli, CORE eConsult implementation teams, and the many clinicians who shared their opinions and experiences with us.

Compliance with Ethical Standards

This study was IRB approved or exempted from review at all participating sites.

Conflict of Interest

Dr. Deeds reports personal consulting fees from Elsevier outside the submitted work. The remaining authors declare no conflicts of interest.


The study reported here was made possible by Grant Number 1C1CMS331324 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Supplementary material

11606_2019_5067_MOESM1_ESM.docx (17 kb)
ESM 1 (DOCX 16 kb)


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Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Stefanie A. Deeds
    • 1
    Email author
  • Kimberly J. Dowdell
    • 2
  • Lisa D. Chew
    • 3
  • Sara L. Ackerman
    • 4
  1. 1.Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Division of General Internal Medicine University of Washington School of MedicineSeattleUSA
  2. 2.Department of Medicine, Division of General, Geriatric, Palliative & Hospital MedicineUniversity of VirginiaCharlottesvilleUSA
  3. 3.Department of Medicine, Harborview Medical Center, Division of General Internal MedicineUniversity of Washington School of MedicineSeattleUSA
  4. 4.Department of Social & Behavioral Sciences, School of NursingUniversity of California, San FranciscoSan FranciscoUSA

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