10 like to know” In many ways in trying to facilitate what should happen at the specialty clinic . . . And this patient will come to me, and he is like, he will go to SFGH and never make a decision . . . I cannot make a decision until I see you (PCP) again, they’re going to do this operation and I want to know what you think. Who am I (as PCP) to make this decision, I am not the specialist who is going to cut into your spinal cord. . .” How do we cut that step out . . . Patient feeling like the PCP needs to be in on the situation . . . This is an example of a reason for me as the PCP being in the same room” “Sometimes specialist may write that oﬀ as an uninterested patient . . . But as a PCP, I feel the duty to translate that for the specialist, and if I can help translate that, we can move the process forward. I would ﬁnd it tremendously helpful if we could use telemedicine to do rounds or when there is one of my patients in the hospital, and they are very complicated patients with social and discharge disposition issues that come up, what I end up having to do, is to page the resident, the attending or the social worker, and stay near the phone and returning calls at various times . . . if I think it’s important enough, I will come into the hospital and have a meeting with the patient, the in house team and myself and perhaps the case manager and myself to work out the discharge plan. It would smooth transitions from the hospital to the community for particularly challenging patients; the in patient team could consult with the outpatient team to work on issues of transitions. Although dependant on a case by case basis, certain “hands free” specialties not requiring touch or cases which would allow for a consultation to occur without mandatory physical presence may render telemedicine technology use- ful. A quote from a provider: “Certain sub specialties lend themselves better to real time telemedicine, I would imagine derma- tology or psychiatry would be a great example of telemedicine in real time, rashes, skin conditions, conversations, you can take photos of everything, and in this case, photos could be very helpful in this circumstance, but maybe not the most perfect example.” 9. Study Limitations This study does not come without limitations. Firstly, the study population is very small and as such, the small sample size utilized in this study calls into question the controversial nature of the validity and reliability traditionally contested in ethnographic research. As a result, care must be taken when International Journal of Telemedicine and Applications interpreting the ﬁndings of this study to ensure the sample size is taken into consideration. Secondly, although it was initially envisioned to have follow up surveys to be sent to the interviewees after conducting the key informant interviews, it was later decided to not administer the survey since there was very little interest in responding to a survey and fear of a very low response rate. Thirdly, engaging the physicians and clinical staﬀ during the interview sessions proved to be quite challenging since it was hard to conceive what could be accomplished with telemedicine without providing concrete examples to guide the interview. Future studies should ensure such examples are prepared in advance of the interview to assist in engaging and guiding the discussion eﬀectively. Finally, a major limitation of the study was that the interview deﬁned a telemedicine scenario for the providers explicitly towards the end of the interview as “videoconferencing,” but then asked participants to consider ways in which telemedicine might be a useful tool in practice and with referrals, thus biasing the concept of telemedicine as videoconferencing and planting this notion in their minds, resulting in suggestions as those mentioned such a dermatology and psychiatry. A follow-up study useful in this context would be to go back to the group and show them a demonstration of the various ways in which telemedicine has been used—the full breadth of its capacity—and then register ideas for telemedicine implementation, to bolster current ﬁndings. 10. Next Steps and Future Work This qualitative study employing ethnographic methods used a selected sample of primary and specialty care providers to gain an in-depth understanding of the current process of patient referral to specialty care services within the safety- net and to improve the delivery of these types of services to patients using telemedicine. The rationale for the inclusion of these types of methods in the study was to ensure the involvement of the actual stakeholders in the decision mak- ing process. Conducting qualitative interviews with the PCP and specialists also served as a means of obtaining general consensus and community buy-in, potentially resulting in the eventual high rate of acceptance of the strategy developed as well as inﬂuence on the behaviour change. The results of the study provide insights and key implications on work and patient ﬂow patterns within the primary and specialty care clinics of the safety net. Key recommendations focus on technical enhancements to the current e-referral interface as well integrating key telemedicine services into the operational and institutional infrastructure of the safety net. Based on the framework proposed, it is recommended that the institution of these changes be adopted within the existing operational and institutional infrastructure of the safety net with little or no additional operational revenue other than the funds required for technology inputs into the system as well as prioritize the institution of these key services for telemedicine by sharing the results with the appropriate work groups and committees