title: Facilitators and barriers to implementing electronic referral and/or consultation systems: a qualitative study of 16 health organizations.
abstract: BACKGROUND
  Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery.
  
  
  METHODS
  Interviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts.
  
  
  RESULTS
  Electronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows.
  
  
  CONCLUSIONS
  eCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives.
authors.affiliation: Division of Nephrology at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. Delphine.tuot@ucsf.edu.|Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. Delphine.tuot@ucsf.edu.
authors.forename: Delphine S
authors.initials: DS
authors.lastname: Tuot
authors.affiliation: Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. leedsk@medsfgh.ucsf.edu.
authors.forename: Kiren
authors.initials: K
authors.lastname: Leeds
authors.affiliation: Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. emurphy@medsfgh.ucsf.edu.|Division of Endocrinology at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. emurphy@medsfgh.ucsf.edu.
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Murphy
authors.affiliation: Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. usarkar@medsfgh.ucsf.edu.
authors.forename: Urmimala
authors.initials: U
authors.lastname: Sarkar
authors.affiliation: Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. Courtney.Lyles@ucsf.edu.
authors.forename: Courtney R
authors.initials: CR
authors.lastname: Lyles
authors.affiliation: Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA.
authors.forename: Tekeshe
authors.initials: T
authors.lastname: Mekonnen
authors.affiliation: Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. Alice.Chen@ucsf.edu.|Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. Alice.Chen@ucsf.edu.
authors.forename: Alice H M
authors.initials: AH
authors.lastname: Chen
mesh_terms: D001331:Automation; D004059:Diffusion of Innovation; D006268:Health Facilities; D006801:Humans; D007407:Interviews as Topic; D011320:Primary Health Care / Q000458:organization & administration; D036301:Qualitative Research; D012017:Referral and Consultation / Q000458:organization & administration*; D013038:Specialization; D014481:United States