International Journal of Telemedicine and Applications physicians in a general conversation regarding information on their current practice and experience with the electronic referral process, with a keen focus on ways in which improve- ments could be made using types of services or programs using telemedicine technology. Semi-structured interviews ranged in duration between 30 and 60 minutes each and were conducted in the speciﬁc primary and specialty care clinic settings. Preliminary qualitative data reveals several key themes pertinent to the study. 8.1. Current Process of Electronic Referrals (E-Referral). The current system of making specialty care referrals between the PCP and the specialists were based on an electronic platform embedded into the EMR. A majority of the providers noted their satisfaction and enthusiasm with the e-referral system and that the institution of this novel approach to accessing specialty care resulted in decreasing the amount of time it took primary care patients to obtain a ﬁrst time appointment with a specialist at SFGH. Some quotes from providers to illustrate this point: “E-referral has allowed us as primary care providers to have better communication with specialists.” “It has helped us (Specialists) decrease our patients’ wait times for an Appointment in our clinic.” “Great thing about e-referral in my opinion (PCP) is that it is a conversation starter. In the past I would refer patients to rheumatology and you would have to wait till the rheumatologist saw you before you could have a conversation about it . . . and with e-referral you are told that you may need to get a CT scan before you see the specialist.” “The e-referral system has signiﬁcantly improved our process; tremendous amount of improvement resulting in a signiﬁcant improvement in our wait times, from nine months to about two months.” “I found e-referral to be quite eﬃcient for me, especially as you build a library of responses.” “E-referral was a fantastic move with this inno- vation in bringing this type of system here, was because we had a notoriously lost somehow somewhere in the system people’s consult request forms, with 40% of patients coming to the clinic and did not have a consultation with them, and we had no idea why these patients were in the clinic, and it was not uncommon for me to page a PCP and ask as to what I should be doing with these patients., and patients would tell me diﬀerent stories and the PCP’s would have a diﬀerent story and e-referral closed that loop.” Even though e-referral has worked tremendously well in vastly improving access to specialists and reduced wait times 5 for an appointment, interviews with providers also revealed some gaps in the system. Some quotes from providers to illustrate: “E-referral is just a mechanism.” “Understanding the e-referral and its intentions, it has worked well to make the referral process much easier and doing some consultation and pre- visit consultation, and almost perhaps has avoided unnecessary visits, that has seemed to work well . . . But actually getting them (specialists) to tell us (PCP) what has happened, and making the feedback loop in the system and making the system more user friendly for the patient, that has remain unchanged.” “We should all have one central medical record, and the specialist and the PCP should have access to all the same information and we should not have paper and that there is no reason in today’s age for me (PCP) to write a note that nobody else can see.” “It would be great to have just like the e-referral system gives you feedback on the front end on e- referral where you end up ﬁnding out right away, we will see your patient or not, or order your tests and then get back to me, its once the patient actually sees the specialist and after the patient sees the specialist, that is when the system begins to break down.” “Right now, we have no way of knowing if a patient was actually seen (in the specialty clinic); until I see the patient the next time, and ask the patient if they could make it to their appointment.” “Sometimes, we can tell if a patient was registered and did not actually complete a visit (specialty), but only if they place a note in the LCR or fax a note to us, but very rarely occurs.” “Diﬀerent clinics (specialty) are better at putting a note in the LCR, and some are not. It’s very patch work and not uniform, diﬀerent clinics have diﬀerent ways of handling that.” “The biggest challenge with the e-referral system is being able to get data or records from some of the outpatient primary care clinics which may not necessarily have the same system as we do, so we are not able to receive that information from our LCR system. It has been a challenge to ensure that our patients come in with that type of information, whether they are in our system or not. We are working very hard to ensure that the media by which we communicate with the primary, has the necessary information that we need transfer to the patient and that the patient brining in that information with them.”