Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
JAMA Intern Med. 2018 Jun 1;178(6):782-789. doi: 10.1001/jamainternmed.2018.0738.
Safety-net health systems across the country are implementing electronic consult (eConsult) systems in which primary care practitioners (PCPs) submit all requests for specialty assistance electronically to be reviewed and discussed with specialists. Evidence suggests that eConsult systems can make significant improvements in specialty access, but the outcomes of these systems for frontline PCPs is poorly understood.
To understand PCP perceptions of the results of eConsult initiation on PCP workflow, specialist access, and patient care.
DESIGN, SETTING, AND PARTICIPANTS: Qualitative interviews were conducted from December 1, 2016, to April 15, 2017, with 40 safety-net PCPs in Los Angeles County who use the Los Angeles County Department of Health Services (DHS) eConsult system. Interviewees were recruited to include diversity in PCP type, practice setting, and employer (DHS employed vs DHS affiliated). Participants were interviewed about their perceptions of clinical workflow, access to specialists, relationships with specialists, and referral decision making.
Perceptions of the results of eConsult, including positive and negative themes and remaining perceived gaps in specialty care.
Of the 40 participants, 27 (68%) were women; 24 (60%) PCPs performed 5 or more eConsults per week. Primary care practitioners' perceptions of eConsult clustered around 4 main themes: access and timeliness of specialty care, shift of work to PCPs, relationships with specialists, and eConsult interface issues. Many PCPs praised the improved timeliness of specialist input with eConsult, as well as the added clinical and educational value of dialogue with specialists, particularly compared with the limitations of the prior referral process. However, PCPs also consistently perceived that eConsult shifted some of the work of specialty care to them. Many PCPs believed that this extra burden was worth the effort given the benefits of eConsult, such as improved timeliness of care and ability to manage specialty conditions. In contrast, others were frustrated by the increased administrative burden, broadened clinical responsibility, and restructuring of specialty care delivery.
While associated with improved specialty care access, eConsult systems simultaneously created new challenges for PCPs, such as an increased burden of work in providing specialty care. Primary care practitioners varied in their enthusiasm for these workflow changes with diverging perceptions of the same processes. Our findings provide insights on challenges future primary care transformation efforts may face.
全美各地的安全网卫生系统正在实施电子咨询（eConsult）系统，初级保健医生（PCP）将所有专业援助请求通过电子方式提交，以供专家审查和讨论。有证据表明，电子咨询系统可以显著改善专业人员的获取途径，但对于一线 PCP 来说，这些系统的结果尚不清楚。
了解 PCP 对电子咨询启动对 PCP 工作流程、专家获取和患者护理结果的看法。
设计、地点和参与者：2016 年 12 月 1 日至 2017 年 4 月 15 日期间，在洛杉矶县进行了定性访谈，采访了 40 名使用洛杉矶县卫生服务部（DHS）电子咨询系统的安全网 PCP。受访者的招募旨在包括 PCP 类型、实践环境和雇主（DHS 雇用与 DHS 附属）的多样性。参与者被问及他们对临床工作流程、专家获取、与专家的关系以及转诊决策的看法。
对电子咨询结果的看法，包括积极和消极的主题以及专业护理方面仍然存在的差距。
在 40 名参与者中，有 27 名（68%）为女性；24 名（60%）PCP 每周进行 5 次或以上的电子咨询。PCP 对电子咨询的看法主要集中在 4 个主题上：专业护理的获取和及时性、工作向 PCP 的转移、与专家的关系以及电子咨询界面问题。许多 PCP 对电子咨询改善了专家意见的及时性以及与专家进行对话的附加临床和教育价值表示赞赏，特别是与之前的转诊流程相比。然而，PCP 们也一直认为，电子咨询将一些专业护理工作转移给了他们。许多 PCP 认为，鉴于电子咨询带来的好处，如改善护理及时性和管理专业条件的能力，这种额外的负担是值得的。相比之下，其他人对增加的行政负担、扩大的临床责任和专业护理服务结构的改变感到沮丧。
虽然与改善专业护理获取有关，但电子咨询系统同时也给 PCP 带来了新的挑战，例如提供专业护理的工作负担增加。初级保健医生对这些工作流程变化的热情各不相同，对相同的流程有不同的看法。我们的研究结果为未来初级保健转型工作可能面临的挑战提供了见解。
