Table 1

Barriers to eConsult implementation using the quadruple aim framework

Provider perspectivePatient perspectiveHealthcare systemCost
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 it54
Increased workload *
Specialists also experienced greater workload in the form of pre-consultative exchange and virtual management, which also served as a barrier to implementation16
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 challenging82
Insufficient remuneration for providers*
A key barrier to widespread adoption of preconsultation exchange is the development of reimbursement models77
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 liability78
Perceived decrease in accessibility to specialist care*
✗ And if I feel like my doctor is brushing off that information, is not communicating other symptoms48
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 infrastructure67
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 consultant15
Loss of patient contact
A minority of them prefer not to use VCs [virtual consults] because of…discomfort with an impersonal process79
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 it48
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 practice67
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 plan80
Privacy concerns*
Concerns over privacy remain a barrier to the adoption of electronic platforms or innovations among health care providers59
Insufficient remuneration to use eConsult
Lack of reimbursement for PCP to submit the consultation request electronically44
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 care81
Challenges related to patient follow-up
Concern about how and when to communicate with patients regarding a consultant’s recommendations55
Insufficient remuneration to use eConsult
Concerns included… the need for adequate protected time and credit15
Receiving timely responses from specialists
PCPs were not satisfied with the depth of the answer that was provided76
  • ✗Selected quotes supporting the theme from the literature.

  • *Preidentified theme (deductive).

  • PCP, primary care provider.