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Ann Fam Med. 2016 Mar;14(2):133-40. doi: 10.1370/afm.1869.

Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial.

Author information

Center for Excellence in Primary Care, San Francisco General Hospital, San Francisco, California Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
Weitzman Institute, Community Health Center, Inc, Middletown, Connecticut.
Rollins School of Public Health, Emory University, Atlanta, Georgia.
Division of Behavioral Sciences and Community Health, University of Connecticut Health Center, Farmington, Connecticut.
Pat and Jim Calhoun Cardiology Center, University of Connecticut Health Center, Farmington, Connecticut.
Department of Statistics, University of Connecticut, Storrs, Connecticut.



Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care.


Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age.


Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group.


E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.

[Indexed for MEDLINE]
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