Evaluation of E-Consults in the VHA: Provider Perspectives

Specialists drove the implementation process across sites. The e-consults were envisioned as a collaborative process; however, during initial interviews, few specialists mentioned PCPs when describing the development and implementation of the e-consult program. Primary care providers also reported having little awareness of or input into how the initiative was implemented, although this had little consequence on the use of e-consults.

In a rare case, a PCP reported that poorly designed, lengthy e-consult templates were a major barrier to using e-consults for specific specialties. The PCP said, “E-consults have created an elaborate but extraordinarily cumbersome tool that is difficult for PCPs to actually accomplish, because you have a consult menu that requires a lot of data to be entered—a lot of history from the chart, a lot of exam findings, a lot of previous cognitive testing scores; neurologic findings—lab and imaging tests.”

Still, many other PCPs described receiving detailed information and guidance from e-consults. “E-consults help me to be more accurate. Many providers don’t have a comfort with pain management. To get guidance and education and to really hold our hand, this is how to do this…this has been a big change. If they give you a great response, then [for] the next patient [with that condition], you go back to that note and then follow what was said there,” said one PCP.

In follow-up interviews, providers and other key staff stated there were more data available on the patient as a result of the e-consult and, consequently, even when specialists determined that a patient needed an in-person visit, the data obtained in the e-consult improved the quality of the in-person consultation.

Enhanced Communication and Collaboration

Neither the PCPs nor the specialists were aware of the collaborative intent of the initiative. They focused, instead, on other key aims, such as increasing accessibility and minimizing unnecessary patient travel. Most participants were generally positive about e-consults during baseline interviews, and this perception increased over time.

Both the PCPs and the specialists reported improved communication following the launch of e-consults. In follow-up interviews, some PCPs reported that before e-consults, they had trouble getting timely responses from specialists unless they knew them personally. “You had to know the person in the old days,” one respondent said. “After e-consults, responses improved…e-consult is available to have the resources to tap that knowledge base, and the team is answering the question. I think it opens up access and information and knowledge to everybody.”

Many PCPs spoke positively about this new communication tool as an opportunity to learn from specialists and said they valued the input they received. They felt the increased interaction between the 2 groups positively benefited patient care. One example cited that collaborative communication improved care coordination for veterans: “We are able to step in with e-consults to coordinate services, and this has been huge in improving care.”

Furthermore, follow-up interviews found that all participating PCPs and specialists were communicating more frequently and effectively. “Services that have embraced e-consult give a lot of great information flowing back; it’s closer to a real-time conversation,” said one respondent. 


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In baseline interviews, some specialists described how e-consults went against their belief that patient care is synonymous with face-to-face medical treatment and voiced dissatisfaction with e-consults as “sitting in front of a computer” rather than “seeing patients.” Others were concerned that medical center administration would not recognize the time it takes to conduct an e-consult and therefore not add necessary specialists staff. “E-consults take work and time, just like seeing a patient. I worry that won’t be seen,” one specialist said.

In order to successfully implement the e-consult initiative, providers and staff needed to incorporate new processes into their daily workflow.

Most sites did not develop a mechanism in which specialists received feedback regarding the outcome of their consultations. This lack of response created anxiety for some specialists in the absence of the face-to-face encounter, leaving some wondering whether they or the PCP had missed anything. According to one specialist, “That’s always in the back of your head: ‘Have I [the specialist] missed something?’”

In follow-up interviews, none of these concerns were raised. Primary care providers tended to speak of the care provided by specialists through e-consults in very positive terms, except in those instances where PCPs felt the e-consult template was difficult to use and required too much time to complete. “I was worried in the beginning about patients thinking less of me, but we ask for help all the time. We’re asking for help and not inconveniencing the patient; they seem to like it very much,” one PCP said.