Objective Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access, cost, quality, and patient and clinician experience and identified the gaps in existing research on these outcomes. Materials and Methods We searched 4 databases for empirical studies published between 1/1/2015 and 2/28/2019 that reported on one or more outcomes of interest. Two investigators reviewed titles and abstracts. One investigator abstracted information from each relevant article, and another confirmed the abstraction. We applied the GRADE criteria for the strength of evidence for each outcome. Results We found only modest empirical evidence for effectiveness of e-consults on important outcomes. Most studies are observational and within a single health care system, and comprehensive assessments are lacking. For those outcomes that have been reported, findings are generally positive, with mixed results for clinician experience. These findings reassure but also raise concern for publication bias. Conclusion Despite stakeholder enthusiasm and encouraging results in the literature to date, more rigorous study designs applied across all outcomes are needed. Policy makers need to know what benefits may be expected in what contexts, so they can define appropriate measures of success and determine how to achieve them.

BACKGROUND: Clinician well-being is a major priority for healthcare organizations. However, the impact of workplace environment on clinicians' well-being is poorly understood. Integrated health systems are a particularly relevant type of practice environment to focus on, given the increasing rates of practice consolidation and integration. OBJECTIVE: To improve understanding of the concerns of primary care clinicians (PCCs) practicing in an integrated health system. DESIGN: We analyzed free-text comment box responses offered on a national survey about care coordination by 555 PCCs in the Veterans Health Administration, one of the largest integrated health systems in the USA. PARTICIPANTS: A total of 555 PCCs who left free-text comments on a national survey of care coordination in the VHA (30% out of 1862 eligible respondents). Demographics and coordination scale scores were similar between respondents who left comments vs. those who did not. APPROACH: The data were coded and analyzed in line with the grounded theory approach. Key themes were identified by team consensus and illustrative quotations were chosen to illustrate each theme. KEY RESULTS: VHA PCCs described some pressures shared across practice environments, such as prohibitive administrative burden, but also reported several concerns particular to integrated settings, including "dumping" by specialists and moral distress related to a concern for patients. Frustrations due to several aspects of responsibility around referrals may be unique to integrated health systems with salaried clinicians and/or where specialists have the ability to reject referrals. CONCLUSION: PCCs in integrated health systems feel many of the same pressures as their counterparts in nonintegrated settings, but they are also confronted with unique stressors related to these systems' organizational features that restrict clinicians' autonomy. An understanding of these concerns can guide efforts to improve the well-being of PCCs in existing integrated health systems, as well as in practices on their way to integration.

Background: We previously developed 2 complementary surveys to measure coordination of care as experienced by the specialist and the primary care provider (PCP). These Coordination of Specialty Care (CSC) surveys were developed in the Veterans Health Administration (VA), under an integrated organizational umbrella that includes a shared electronic health record (EHR). Objective: To develop an augmented version of the CSC-Specialist in the private sector and use that version (CSC-Specialist 2.0) to examine the effect of a shared EHR on coordination. Research Design: We administered the survey online to a national sample of clinicians from 10 internal medicine subspecialties. We used multitrait analysis and confirmatory factor analysis to evaluate the psychometric properties of the original VA-based survey and develop an augmented private sector survey (CSC-Specialist 2.0). We tested construct validity by regressing a single-item measure of overall coordination onto the 4 scales. We used analysis of variance to examine the relationship of a shared EHR to coordination. Results: Psychometric assessment supported the 13-item, 4-scale structure of the original VA measure and the augmented 18-item, 4-scale structure of the CSC-Specialist 2.0. The CSC-Specialist 2.0 scales together explained 45% of the variance in overall coordination. A shared EHR was associated with significantly better scores for the Roles and Responsibilities and Data Transfer scales, and for overall coordination. Conclusions: The CSC-Specialist 2.0 is a unique survey that demonstrates adequate psychometric performance and is sensitive to use of a shared EHR. It can be used alone or with the CSC-PCP to identify coordination problems, guide interventions, and measure improvements.

Research Objective Coordination of care between specialists and primary care clinicians (PCCs) is a critical component of providing patients with high‐quality specialty care. Previous research has demonstrated care coordination may benefit from use of a shared electronic health record (EHR). Yet reliance on a shared EHR may undercut opportunities to build and maintain personal and professional relationships among clinicians, a factor also positively associated with care coordination. We examine how use of a shared EHR and personal relationships between clinicians interact to influence medical specialists’ experiences of coordination with PCCs. Study Design We surveyed a national sample of clinicians from 10 medical specialties concerning their experiences of care coordination with referring PCCs. Participants completed the Coordination of Specialty Care (CSC)‐Specialist Survey 2.0 which comprehensively assesses coordination with referring PCCs as experienced by the specialist across four domains: mutually respectful relationships (Relationships), clarity and agreement on roles and responsibilities (Roles and Responsibilities), timely and helpful communication (Communication), and timely access to well‐organized patient data (Data Transfer). The survey also included single‐item measures assessing Overall Coordination, proportion of referring PCCs the specialist knew personally, and proportion of referring PCCs with whom they shared an EHR. Multiple regression analyses assessed the independent and interactive influence of shared EHR and personal relationships on specialists’ experiences of coordination after controlling for age, gender, and percentage of work in outpatient care. Population Studied Participants (analysis N = 514) were medical specialist members of the American College of Physicians (ACP) or a participating society in the ACP Subspecialty Societies (ACP CSS). All received an emailed link to complete the survey online. Principal Findings Specialists experienced better coordination if they reported knowing more referring physicians personally, in terms of both Overall Coordination (B = 0.30, P < .0001) and each of the four separately assessed coordination domains: Relationships (B = 0.14, P < .0001); Roles and Responsibilities (B = 0.19, P < .0001); Communication (B = 0.18, P < .0001); and Data Transfer (B = 0.12, P = .001). Having a shared EHR with more referring physicians was positively associated with better Overall Coordination (B = 0.21, P < .0001) and Data Transfer (B = 0.28, P < .0001). The extent of shared EHR also moderated the effect of knowing referring PCCs personally on some aspects of care coordination. For both Overall Coordination and Relationships, the influence of knowing PCCs personally was significantly stronger in the absence of a shared EHR (interactions: B = ‐0.09, P = .03, and B = ‐0.04, P = .04, respectively). However, these interactions accounted for <1% of the variance in reported experiences of coordination. Conclusions Both having a shared EHR and having personal relations...