E-consult implementation: lessons learned using consolidated framework for implementation research.

In 2010, the Secretary for the Department of Veterans Affairs (VA) identified improving access to care as a top priority.1 The Veterans Health Administration (VHA) had been collecting and analyzing data on wait times for more than a decade, and observational studies found associations between wait times and poorer short- and long-term quality indicators.2 Research also highlighted challenges faced by veterans in rural communities and by female veterans, with travel demands and transportation difficulties sometimes exacerbated by veterans’ functional status, resulting in delayed or forgone care.3,4 Technology was seen as part of the solution by offering alternate ways to access care.5 Research suggested telehealth interventions could improve access, including speeding time to treatment while achieving results similar to in-person visits in terms of patient satisfaction and experience of care.6 Simultaneously, there were concerns about implementation of new technologies introducing problems such as privacy and confidentiality vulnerabilities and disruption to clinic work flow.7 In 2011, the VHA implemented specialty care electronic consults (e-consults) at 15 pilot sites. E-consults offer primary care providers (PCPs) the option to obtain specialty care expertise by submitting patient consults via the VHA’s electronic health record (EHR)8,9; e-consults have been implemented in other healthcare systems as well.10-13 Specialists then respond with advice and/or recommendations on whether veterans should be seen in person. If implemented effectively, e-consults should improve specialty care access and reduce travel for veterans. The VHA’s Office of Specialty Care Transformation (OSCT), which was responsible for overseeing the dissemination of e-consults, requested assistance in identifying the challenges associated with implementation to facilitate further dissemination. Thus, the Specialty Care Evaluation Center was created to evaluate e-consult implementation. We used the Consolidated Framework for Implementation Research (CFIR) to identify those factors that facilitated or hindered e-consult implementation among pilot sites. The CFIR consolidates and standardizes definitions of implementation factors, thereby providing a pragmatic structure for identifying potential influences on implementation and comparing findings across sites and studies.14,15 The CFIR is composed of 5 domains: intervention characteristics, outer setting, inner setting, characteristics of individuals involved in implementation, and the process of implementation.14 Thirty-seven constructs characterize these domains. The objective of this study is to use the CFIR for identification and comparison of implementation factors across sites in an effort to learn from their experiences.