Hindawi Publishing Corporation International Journal of Telemedicine and Applications Volume 2011, Article ID 523161, 14 pages doi:10.1155/2011/523161 Research Article Identifying Telemedicine Services to Improve Access to Specialty Care for the Underserved in the San Francisco Safety Net Ken Russell Coelho1, 2 1 Global Health Sciences, University of California, San Francisco, 50 Beale Street, Suite 1300, San Francisco, CA 94143, USA 2 Performance Improvement and Patient Safety Division, San Francisco General Hospital & Trauma Center, 1001 Potrero Avenue, Bldg 20, 3rd Floor, Suite 2300, San Francisco, CA 94110, USA Correspondence should be addressed to Ken Russell Coelho, kencoelho@alumni.ucsf.edu Received 13 May 2011; Revised 20 July 2011; Accepted 26 July 2011 Academic Editor: Velio Macellari Copyright © 2011 Ken Russell Coelho. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Safety-net settings across the country have grappled with providing adequate access to specialty care services. San Francisco General Hospital and Trauma Center, serving as the city’s primary safety-net hospital, has also had to struggle with the same issue. With Healthy San Francisco, the City and County of San Francisco’s Universal Healthcare mandate, the increased demand for specialty care services has placed a further strain on the system. With the recent passage of California Proposition 1D, infrastructural funds are now set aside to assist in connecting major hospitals with primary care clinics in remote areas all over the state of California, using telemedicine. Based on a selected sample of key informant interviews with local staﬀ physicians, this study provides further insight into the current process of e-referral which uses electronic communication for making referrals to specialty care. It also identiﬁes key services for telemedicine in primary and specialty care settings within the San Francisco public health system. This study concludes with proposals for a framework that seek to increase collaboration between the referring primary care physician and specialist, to prioritize institution of these key services for telemedicine. 1. Research Question Primary questions: (1) to determine key services for telemedicine in primary care and specialty care settings of the San Francisco public health system; (2) to determine a framework within the safety net to prioritize institution of key services for telemedicine. 2. Background and Signiﬁcance Safety-net settings across the country have struggled with providing adequate access to specialty care services. To explain, a 2002 case study conducted in ﬁve cities in the United States found that capacity was strained for specialty care services with some cities reporting wait times of up to a year for types of specialty care services [1]. While a country- wide problem in general particularly in California where patients report having diﬃculties in obtaining appointments for specialty care services. A 2002-2003 telephone survey of medical directors of all 101 Federally Qualiﬁed Health Centers in the state found that 85% of respondents reported that their uninsured patients “often” or “almost always” had diﬃculties in obtaining specialty care; 41% reported similar diﬃculties for Medicaid patients [2]. San Francisco has had to deal with the same issue. As the primary safety-net hospital for the City of San Francisco, SFGH is committed to providing specialty care for all the city’s residents regardless of their ability to pay, including the city’s uninsured and the Medicaid and Medicare patients. Although it was not long until the advent of e-referral, San Francisco General Hospital’s electronic specialty care referral system was characterized by a process called “triage by hassle,” [3] which refers to the extra eﬀort both primary and specialty care providers had to make in order to expedite the specialty care referral process of a patient with an urgent condition. The extra eﬀort of the providers in this case would often take the form of numerous handwritten referrals, faxes, phone calls, and pages. Thus, variation in the length