6 “The patient shows up to see me, they do not actually know what’s going on with them, and I look at the LCR and do not see a note and so then I have to spend considerable amount of time either calling the (specialty) clinic and asking someone to fax me the note . . . which is not as simple as . . . “Hey I need this” they’re like wait a minute, let me go look, and ask me to hold on, and that . . . or I have to send an interdepartmental request for information to medical records department to fax over the notes . . . so I do not have any real time access and cannot do any real time work and I do not have the data I need to it to follow up or to help the patient out.” “E-referral has incredible capacity to make changes, but it would need a whole lot of more infusion of support to see its potential, otherwise it has the risk of becoming primarily a tracked referral system with appointment time setting, and less of what the original vision, which would be a modality for training and education of providers, improving care . . . it does improve care on many levels, but I do not think it reaches its full capacity because if the clinics are getting e-referral reviewers faced with 25–50 e-referral requests per day.” Overall, comments from the interviews revealed gaps in the referral process. Examples of these gaps include (1) inconsistent feedback loops back to the PCP after conducting a speciﬁc specialty visit, (2) Receiving medical records from a variety of specialty clinics in diﬀerent electronic or paper for- mats, and (3) the inability to eﬃciently track if a patient does not show up for their subspecialty appointments unless oth- erwise noted in the patient visit history section of the LCR. Patient “No Shows”. Majority of primary care clinics track their patient “No show” rates; however this is done in a nonstandardized manner. As a step in the direction of keeping track of the “no shows” as well as maintaining control over the process improvement, patients not showing up for their appointments with specialists were being tracked by an MEA or Registered Nurse or in certain circumstances, the Medical Director of the clinic track this information and record it into an excel spreadsheet or a sheet of paper. The San Francisco City-Wide, COPC Quality Improvement Committee decided to focus on reducing their “no show” rate as part of their annual performance improvement initiative and to work towards optimizing eﬀective use of their resources. A major concern with this change in the process was that medical evaluation assistant and ancillary staﬀ faced constant barriers in trying to obtain access to the e-referral system due to restrictions in its use amongst the nonclinical community. In addition to these central themes in the gaps, other challenges included the need to order certain diagnostic workups in advance of the specialist visit. Even though diagnostic tests such as specialized procedures (e.g., GI International Journal of Telemedicine and Applications Colonoscopy/Endoscopy) for high need, high impact spe- cialties are pushed to be completed in advance of the specialty visit, additional review is usually required for these types of e-referrals. This additional review proved to delay a patient from being able to eﬀectively complete the specialist visit process which in turn caused a delay in follow-up care at the primary care level. At times, these additional checks also proved to be a deterrent for patients to complete the initial visit to the hospital, aﬀecting their ability to complete a specialist referral. Quote to illustrate a concern with a provider: E-referral has not allowed us to have appoint- ments any earlier than before, and in the case of certain specialties, GI more particularly, it has made it diﬃcult for us to have patients be seen, Gastroenterology as a specialty is much less likely to schedule an appointment for a specialty referral and is probably because they have been overwhelmed and have become much more selective and I am sure it is evidence based. The criteria for patients getting a colonoscopy are much more selective than other specialties, and within our system, no one can get a screening colonoscopy, we just do not have the resources for that. In this case, a screening colonoscopy would be important for the early detection of colorectal cancer, for which one of the standards of care is to obtain a colonoscopy once every ten years, but we do not have the resources to do that, so we use a faecal occult blood test every year. We have patients who have a family history or have had a previous colonoscopy where polyps were found and for those patients it is where we err on the conservative side, and ration care. Moreover, a PCP may also not be aware if a patient may or may not have completed these pre- and postvisits for the diagnostic workup or specialists visit until six to eight months later in certain circumstances. In addition, patients may also be scheduled for these types of visits too soon at times, resulting in appointment letters being mailed out too soon and possibly resulting in patients not showing up for the specialist visit. A quote to illustrate: We are committed to checking e-referrals for our clinic (specialty) 3 days a week at a very minimum and I think it happens on a daily basis and we can book people into our clinic as quickly as the following week. So, in fact when we ﬁrst launched e-referral the ﬁrst 6–9 months, our no show rates increased for a period of time. I do not have formal numbers for this, but we really noticed a creep up of our no shows, but then we found out that we were reviewing e-referrals so quickly, booking their appointments so quickly, and patients never got any letter for their appointment until after their appointment dates passed. So, now we are