• Sharon Rikin, Chenshu Zhang, Daniel Lipsey, Joseph Deluca, Eric J Epstein, Matt Berger, Yaron Tomer, and Julia H Arnsten.
• Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA. Srikin@montefiore.org.
• J Gen Intern Med. 2020 Nov 1; 35 (Suppl 2): 832-838.

BackgroundeConsult programs have been instituted to increase access to specialty expertise. Opt-in choice eConsult programs maintain primary care physician (PCP) autonomy to decide whether to utilize eConsults versus traditional specialty referrals, but little is known about how this intervention may impact PCP eConsult adoption and traditional referral demand.ObjectiveWe assessed the feasibility of implementing an opt-in choice eConsult program and examined whether this intervention reduces demand for in-person visits for primary care patients requiring specialty expertise.DesignStepped-wedge, cluster randomized trial conducted from July 2018 to June 2019.ParticipantsSixteen primary care practices in a large, urban academic health care system.InterventionOur intervention was an opt-in choice eConsult available in addition to traditional specialty referral; our implementation strategy included in-person training, audit and feedback, and incentive payments.Main MeasuresOur implementation outcome measure was the eConsult rate: weekly proportion of eConsults per PCP visit at each site. Our intervention outcome measure was traditional referral rate: weekly proportion of referrals per PCP visit at each site. We also assessed PCP experiences with questionnaires.Key ResultsOf 305,915 in-person PCP visits, there were 31,510 traditional referrals to specialties participating in the eConsult program, and 679 eConsults. All but one primary care site utilized the opt-in choice eConsult program, with a weekly rate of 0.05 eConsults per 100 PCP visits by the end of the study period. The weekly rate of traditional referrals was 11 per 100 PCP visits at the end of the study period; this represents a significant increase in traditional referral rate after implementation of eConsults. PCPs were generally satisfied with the eConsult program and valued prompt provider-to-provider communication.ConclusionsImplementation of an opt-in choice eConsult program resulted in widespread PCP adoption; however, this did not decrease the demand for traditional referrals. Future studies should evaluate different strategies to incentivize and increase eConsult utilization while maintaining PCP choice.

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