International Journal of Telemedicine and Applications 7 Table 1: Increased collaboration between the PCP and specialist. Referral from PCP Ex: video ﬁle option (MPEG) with speech recognition transcription software embedded into electronic referral system. Requires recording apparatus such as a webcam on the computer. This could occur in presence of patient or PCP alone. Feedback from specialist Ex: expanding library of responses with the option of customizing free text linked to the medical literature/pub med databases for automated citations of peer-reviewed literature. Possibility of saving time and improving eﬃciency and reliability in design. Centralized tracking for “no shows” and “come and go’s”/reminders Ex: automated phone call reminders “one day” in advance of visit, “no show” and “come and go” tracking within e-referral for both PCP and specialist. more routinely booking people two weeks out even though we could take them in faster. 8.2. Key Recommendations for Improvements in E-Referral. Key recommendation for an improvement in the current system includes the expansion of e-referral to increase collaboration between PCP and the Specialist. This can be accomplished by the following: (1) facilitating the initiation of referrals from the PCP to the specialists; (2) incentivising the specialists to provide more timely feedback to the PCP during the e-referral process itself and to include feedback after the onsite subspe- cialty visit; (3) reducing barriers for both the PCP and specialist to centrally track patients who do not show up for their appointments (no Shows), or for some reason or the other decide to leave the clinic before being seen by the specialist (come and go’s). Key informant interviews with providers revealed a brief list of examples of e-referral improvements. A summary of the speciﬁc examples of the ways in which an enhanced level of collaboration between the PCP and the specialist could be accomplished is shown in Table 1. Some of the interviews also revealed that some sub- specialty groups at SFGH were working on a provider- referral algorithm which would likely introduce more reli- ability within the current system and ultimately deﬁne set turnaround time frames and approved guidelines for certain type of specialty referrals. There is a task force or a work group that is currently reviewing this algorithm as a potential improvement to the e-referral system. 8.3. Videoconferencing Technology for Telemedicine. When PCP and specialists were asked about the use of videocon- ferencing technology during the referral process, a variety of mixed opinions were expressed. Some quotes to illustrate: “Making e-referral more interactive with video- conference may not be as valuable as you think it may, since it will inevitably impact my patient ﬂow and is not worth it. The interesting thing about e-referral is that you do at the end of the visit . . . Say for example you are with the patient for 15 minutes and in the last 2-3 minutes you place an e-referral . . . You have already budgeted time to be with the patient . . . And if then at that time you decide or know of the option to videoconference in to increase the interaction in e-referral, then it will have already impacted the patient ﬂow.” “We have many Spanish speaking patients, so, we could use videoconferencing technology for lan- guage interpreters and that would be important.” “Physical examinations would be hard to do through videoconferencing technology, but they could get the process started, build a connection with the patient so that they could feel more comfortable to see the specialist at some point.” “A majority of the patients referred to our specialty would require the need for the patient to complete a thorough physical evaluation with any of us, before a patient could be referred to a diagnostic test or even a follow up visit. The same exists with patients requiring other specialist services.” “Videoconferencing works beautifully for trans- lation . . . You could consider doing it instead of clinic spots instead of having them come to you . . . but I’m not sure if that would be doing the patient a service, this could be a diﬀerent service we could provide, but it would be a separate clinic and would be called telemedicine clinic.” However, videoconferencing technology may be useful for those patients who may not ordinarily show up for a routinely scheduled appointment or for those patients living in “hard to reach” areas of the city. For example, a primary care provider summarizes, “In situations where patients who are psychiatri- cally impaired or have mobility issues and come in for evaluation of a rare GI Mass or a tumour or complex rheumatologic case wherein a group of symptoms may need to be reviewed and a patient may not be in a position to make it to his or her appointment, video conferencing technology may vastly improve their access to a specialist.”