The Evolution of Primary Care Telehealth Disparities During COVID-19: Retrospective Cohort Study.

BACKGROUND: Telehealth has become widely used as a novel way to provide outpatient care during the COVID-19 pandemic, but data about telehealth use in primary care remain limited. Studies in other specialties raise concerns that telehealth may be widening existing health care disparities, requiring further scrutiny of trends in telehealth use. OBJECTIVE: Our study aims to further characterize sociodemographic differences in primary care via telehealth compared to in-person office visits before and during the COVID-19 pandemic and determine if these disparities changed throughout 2020. METHODS: We conducted a retrospective cohort study in a large US academic center with 46 primary care practices from April-December 2019 to April-December 2020. Data were subdivided into calendar quarters and compared to determine evolving disparities throughout the year. We queried and compared billed outpatient encounters in General Internal Medicine and Family Medicine via binary logic mixed effects regression model and estimated odds ratios (ORs) with 95% CIs. We used sex, race, and ethnicity of the patient attending each encounter as fixed effects. We analyzed socioeconomic status of patients in the institution's primary county based on the patient's residence zip code. RESULTS: A total of 81,822 encounters in the pre-COVID-19 time frame and 47,994 encounters in the intra-COVID-19 time frame were analyzed; in the intra-COVID-19 time frame, a total of 5322 (11.1%) of encounters were telehealth encounters. Patients living in zip code areas with high utilization rate of supplemental nutrition assistance were less likely to use primary care in the intra-COVID-19 time frame (OR 0.94, 95% CI 0.90-0.98; P=.006). Encounters with the following patients were less likely to be via telehealth compared to in-person office visits: patients who self-identified as Asian (OR 0.74, 95% CI 0.63-0.86) and Nepali (OR 0.37, 95% CI 0.19-0.72), patients insured by Medicare (OR 0.77, 95% CI 0.68-0.88), and patients living in zip code areas with high utilization rate of supplemental nutrition assistance (OR 0.84, 95% CI 0.71-0.99). Many of these disparities persisted throughout the year. Although there was no statistically significant difference in telehealth use for patients insured by Medicaid throughout the whole year, subanalysis of quarter 4 found encounters with patients insured by Medicaid were less likely to be via telehealth (OR 0.73, 95% CI 0.55-0.97; P=.03). CONCLUSIONS: Telehealth was not used equally by all patients within primary care throughout the first year of the COVID-19 pandemic, specifically by patients who self-identified as Asian and Nepali, insured by Medicare, and living in zip code areas with low socioeconomic status. As the COVID-19 pandemic and telehealth infrastructure change, it is critical we continue to reassess the use of telehealth. Institutions should continue to monitor disparities in telehealth access and advocate for policy changes that may improve equity.

Capacity to Address Social Needs Affects Primary Care Clinician Burnout.

PURPOSE: Primary care clinicians disproportionately report symptoms of burnout, threatening workforce sustainability and quality of care. Recent surveys report that these symptoms are greater when clinicians perceive fewer clinic resources to address patients' social needs. We undertook this study to better understand the relationship between burnout and clinic capacity to address social needs. METHODS: We completed semistructured, in-person interviews and brief surveys with 29 primary care clinicians serving low-income populations. Interview and survey topics included burnout and clinic capacity to address social needs. We analyzed interviews using a modified grounded theory approach to qualitative research and used survey responses to contextualize our qualitative findings. RESULTS: Four key themes emerged from the interview analyses: (1) burnout can affect how clinicians evaluate their clinic's resources to address social needs, with clinicians reporting high emotional exhaustion perceiving low efficacy even in when such resources are available; (2) unmet social needs affect practice by influencing clinic flow, treatment planning, and clinician emotional wellness; (3) social services embedded in primary care clinics buffer against burnout by increasing efficiency, restoring clinicians' medical roles, and improving morale; and (4) clinicians view clinic-level interventions to address patients' social needs as a necessary but insufficient strategy to address burnout. CONCLUSIONS: Primary care clinicians described multiple pathways whereby increased clinic capacity to address patients' social needs mitigates burnout symptoms. These findings may inform burnout prevention strategies that strengthen the capacity to address patients' social needs in primary care clinical settings.

The impact of patient advisors on healthcare outcomes: a systematic review.

BACKGROUND: Patient advisory councils are a way for healthcare organizations to promote patient engagement. Despite mandates to implement patient advisory councils through programs like the Patient-Centered Medical Home (PCMH), there is a paucity of data measuring the impact of patients functioning in advisory roles. Our objective is to investigate whether patient engagement in patient advisory councils is linked to improvements in clinical quality, patient safety or patient satisfaction. METHODS: We searched PubMed, SCOPUS, CINAHL and Google Scholar for English language publications between November 2002 to August 2015, using a combination of "patient advisor" and "care outcomes" search terms. Article selection utilized dual screening facilitated by DistillerSR software, with group discussion to resolve discordance. Observational studies, randomized controlled trials, and case studies were included that described patients serving in an advisory role where primary outcomes were mentioned. Reference lists of included studies and grey literature searches were conducted. Qualitative thematic analysis was performed to synthesize results. RESULTS: Database searching yielded 639 articles total after removing duplicates, with 129 articles meeting full text inclusion criteria. 32 articles were identified for final review, 16 of which were case studies. Advisory roles included patient advisory councils, ad-hoc patient committees, community advisory councils, experience-based co-design, and other. Four practice-based studies from one research group, involving community advisors in the design of public health interventions, found improved clinical outcomes. No prospective experimental studies assessed the impact of patient advisors on patient safety or patient satisfaction. One cluster-randomized RCT showed that patient advisors helped health care planning efforts identify priorities more aligned with the PCMH. Ten case studies reported anecdotal benefit to individual patient advisors. CONCLUSION: Five included studies demonstrate promising methods for evaluating patient engagement in healthcare delivery and describe impacts on clinical outcomes and priority setting. Based on the case studies found, patient advisors tend to contribute to patient-facing services that may affect clinical care but are not easily evaluated. As clinics and hospitals implement patient advisory councils, rigorous evaluation of their programs is needed to support the expansion of system-level patient engagement. TRIAL REGISTRATION: This systematic review was registered in the PROSPERO database of the University of York Centre for Reviews and Dissemination (ID: 2015: CRD42015030020 ).

Racism in Medicine: Shifting the Power.

Medicine has historically been a field where the provider of the service (physician, nurse) has a significant amount of power as compared with the recipient of the service (the patient). For the most part, this power is relatively consistent, and the power dynamic is rarely disrupted. In this essay, I share a personal experience in which a racist rant by a patient seemingly reverses the power dynamic. As the physician, I faced the realization that I may not have as much power as I believed, but fortunately I had some tools that allowed for my resilience. It is my hope that this paper will strengthen other family physicians and professional minorities that are victims of racism, discrimination, and prejudice for their race, sex, ability, sexual orientation, religion, and other axes of discrimination.

Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial.

PURPOSE: Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care. METHODS: Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age. RESULTS: Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group. CONCLUSION: E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.

Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization.

Sickle cell disease (SCD) has a history of health inequity, as patients with SCD are primarily Black and often marginalized from the health care system. Although recent health care and treatment advancements have prolonged life expectancy, it may be insufficient to support the complex needs of the growing population of older adults with SCD. This retrospective study used a cohort (N = 812) of Medicare Advantage beneficiaries 45 years and older (ages: 45-54, 55-64, 65-74, 75-89) with SCD to identify associations of SCD-related complications and comorbidities with emergency department (ED) visits, potentially avoidable ED visits, all-cause hospitalization, and potentially avoidable hospitalizations, 2018-2020. The 75-89 age group had lower odds of an ED visit (OR 0.56; 95% CI 0.32-1.00), 65-74 age group had lower odds of an ED visit (OR 0.49; 95% CI 0.31-0.78) and hospitalization (OR 0.50; 95% CI 0.31-0.79), compared with the 45-54 age group. Acute chest syndrome was associated with increased odds of an ED visit (OR 2.02; 95% CI 1.10-3.71), avoidable ED visit (OR 1.87; 95% CI 1.14-3.06), and hospitalization (OR 3.61; 95% CI 2.06-6.31). Pain was associated with increased odds of an ED visit (OR 2.64; 95% CI 1.85-3.76), an avoidable ED visit (OR 3.08; 95% CI 1.90-4.98), hospitalization (OR 1.51; 95% CI 1.02-2.24), and avoidable hospitalization (OR 6.42; 95% CI 1.74-23.74). Older adults with SCD have been living with SCD for decades, often while managing pain crises and complications associated increased incidence of an ED visit and hospitalization. The characteristics and needs of this population must continue to be examined to increase preventative care and reduce costly emergent health care resource utilization.

Screening for health literacy, social determinants, and discrimination in health plans.

OBJECTIVES: Health inequities are frequently driven by social determinants of health (SDOH) and structural determinants of health. Our pilot sought to test the feasibility of screening for health literacy (HL) and perceived health care discrimination (PHD) through a live telephonic-facilitated survey experience with managed care patients. STUDY DESIGN: Cross-sectional study. METHODS: Newly enrolled Medicare Advantage patients were screened for self-reported PHD, HL, and multiple SDOH using validated screening tools. Response rates for both HL and PHD screens were analyzed. A χ2 test for association between response to PHD screen and patient race was conducted. A weighted logistic regression model was used to understand how HL is associated with SDOH and demographic factors (age, gender, race/ethnicity, and income). RESULTS: HL and PHD screening questions have different levels of feasibility. Administering the HL screen did not present a challenge, and patients felt comfortable responding to it. On the other hand, the PHD question had a lower response rate among patients, and some concierge advocates felt uncomfortable asking patients the question. Based on the self-reported HL data collected, low/limited HL is associated with patients who were Black, were low income, reported loneliness or isolation, or reported food insecurity. It is important to note that the study's findings are limited by the small sample size and that study results do not imply causality. CONCLUSIONS: It is feasible to collect self-reported HL data through a live telephonic format at the time of patient enrollment into a health plan. Health plans can leverage such screenings to better understand patient barriers for health equity-oriented interventions.

Telemedicine-based digital retinal imaging vs standard ophthalmologic evaluation for the assessment of diabetic retinopathy.

OBJECTIVE: To study the cost benefit analysis of using a telemedicine-based digital retinal imaging evaluation compared to conventional ophthalmologic fundus examination of diabetic patients for diabetic retinopathy. METHODS: In this study, diabetic patients from Community Health Center, Inc. (CHCI), a large multi-site Federally Qualified Health Center) were evaluated by teleophthalmology using the Canon CR-1 nonmydriatic fundus camera. Digital images were acquired in the CHCI offices and saved on the EyePACS server network. The images were later evaluated by retinal specialists at the Yale Eye Center, Yale University Department of Ophthalmology and Visual Science. The costs for the standard of care ophthalmic examinations were calculated based on 2009 Medicaid reimbursement rates. The process of telemedicine-based diagnosis was based on a take-store-forward-visualize system. The cost of telemedicine-based digital retinal imaging examination included cost for devices, training, annual costs and a transportation fee. Current Medicaid reimbursement, transportation, and staff labor costs were used to calculate the conventional retinal examination cost as a comparison. RESULTS: Among the 611 patients digital retinal images screened in the first year of this program and for whom data are available, 166 (27.2%) cases of diabetic retinopathy were identified. Seventy-five (12.3%) patients screened positive with clinically significant disease and were referred for further ophthalmological evaluation and treatment. The primary direct cost of the telemedicine was $3.80, $15.00, $17.60, $1.50, and $2.50 per patient for medical assistant, ophthalmologist, capital cost (Equipment + Training), equipment maintenance, and transportation fee, respectively. The total cost in the telemedicine-based digital retinal imaging and evaluation was $40.40. The cost of conventional retinal examination was $8.70, $65.30, and $3.80 per patients for round-trip transportation, 2009 national Medicaid Physician Fee Schedule allowable for bilateral eye examination, and medical assistant personnel, respectively. The total costs of conventional fundus examination were $77.80. An additional conventional ophthalmologic retinal examination was required for 75 (12.3%) patients with clinically significant disease on telemedicine evaluation, which involves an averaged additional cost of $ 9.55 per patient for all the patients in the study. If the cost of subsequent examination was added, the total cost of telemedicine-based digital fundus imaging was $49.95 per patient in our group of 611 patients evaluated. CONCLUSIONS: Our cost analysis indicates that telemedicine-based diabetic retinopathy screening cost less ($49.95 vs $77.80) than conventional retinal examination and the telemedicine-based digital retinal imaging examination has the potential to provide an alternative method with greater convenience and access for the remote and indigent populations. Diabetes mellitus and diabetic retinopathy are growing problems in the United States and worldwide. Large scale adoption of telemedicine should be encouraged as a means toward providing improved access, increasing compliance with annual evaluation, at a low cost for patients with diabetes with direct access to an eye care specialist.

Pathways to equity: A pilot study implementing a health equity leadership curriculum in residency education as an antidote to systemic racism.

BACKGROUND: Health disparities negatively impact the lives of patients and are a product of the social categorization of medicine. In dismantling the systemic racism and biases that create health disparities, health equity curricula can be implemented that improve resident physician awareness and competency in caring for patients from vulnerable populations. OBJECTIVE: The objective of this study is to assess the impact of a resident-led health equity curriculum on the self-efficacy of family medicine residents in caring for vulnerable populations and managing challenging patient scenarios. METHODS: The Health Equity Leadership Concentration (HELC) curriculum was implemented in the fall of 2019. Residents self-selected their participation in the concentration and completed pre- and 6-month post- implementation surveys on self-efficacy. Deidentified survey data were analyzed with α = 0.05 significance level. RESULTS: Eight residents of 26 residents self-selected to participate (30%) with pre- and post- implementation survey response rates of 100% and 87.5% (HELC) and 66.7% and 88% (general residents). A significant increase in self-efficacy was observed in caring for the uninsured (p=0.007), LGBTQ (P=0.047), and Immigrant (p=0.04) populations and managing food insecurity (p=0.01) after 6 months in the HELC curriculum. No significant increases were seen in the general resident curriculum. HELC residents had a significant increase in self-efficacy in caring for the Medicaid population (p=0.048) in comparison with the general residents. CONCLUSIONS: The HELC was successful in increasing self-efficacy in caring for vulnerable populations and managing challenging patient scenarios at 6-months. Further evaluation is needed for generalizability and determination of true statistical significance.

Sounding the Alarm: Six Strategies for Medical Students to Champion Anti-Racism Advocacy.

Every year, incoming medical students take the Hippocratic Oath and pledge that they: "will be an advocate for patients in need and strive for justice in the care of the sick," yet guidance on how to engage in community and public health advocacy is not a mandatory component of medical education. Therefore, students often feel insufficiently qualified to engage in advocacy efforts. As the nation has struggled with a viral pandemic (COVID-19) and witnessed an uprising against anti-Black racism and police brutality, it became immediately apparent that activism that marries medicine to anti-racism advocacy was needed. Further, we deduced that anti-racism activism at medical institutions would need to position medical students, often low in the medical hierarchy, as essential to the response. With the support of our leaders and mentors, we created a concerted series of strategies for medical students to become front and center in advocacy efforts. In this paper, we outline six strategies for medical students across the nation to champion anti-racism advocacy, based on our successful experiences in Central Ohio. This approach may have utility for other medical schools across the nation. These strategies include: embracing a common agenda; establishing formal structures; engaging affinity groups and allies; endorsing legislative advocacy; encouraging curricular reform; and enriching the pipeline. It is our hope that medical students will feel empowered and activated to lead and organize "good trouble" efforts that will ultimately improve the lives and health of the communities and patients they are being trained to serve.

Electronic Consultations as an Educational Tool to Improve the Care of Transgender Patients in Primary Care.

Electronic consultations (eConsults) have demonstrated benefits in many areas of clinical care including educational value for primary care clinicians (PCCs). It has been shown that few PCCs have knowledge and confidence to manage transgender and gender non-binary (TGNB) patients. In this report, we explored the impact of eConsults submitted to a TGNB specialist panel on PCC experience and on their education on TGNB-related topics. We conducted a retrospective review of de-identified data from the RubiconMD electronic consultation platform used by PCCs in 36 U.S. states for eConsults submitted to the TGNB specialty. We found that 90% of eConsults were from federally qualified health centers, other community clinics, and rural areas. Primary care clinicians reported outcomes as "educational" for 50% and "improved care plan" for 88% of eConsults. These results suggest that eConsults play an important role in educating PCCs on TGNB care and may also lead to improved PCC and patient experiences.

Telehealth as a Bright Spot of the COVID-19 Pandemic: Recommendations From the Virtual Frontlines ("Frontweb").

The coronavirus disease (COVID-19) pandemic has accelerated the telehealth tipping point in the practice of family medicine and primary care in the United States, making telehealth not just a novel approach to care but also a necessary one for public health safety. Social distancing requirements and stay-at-home orders have shifted patient care from face-to-face consultations in primary care offices to virtual care from clinicians' homes or offices, moving to a new frontline, which we call the "frontweb." Our telehealth workgroup employed the Clinical Transformation in Technology implementation framework to accelerate telehealth expansion and to develop a consensus document for clinician recommendations in providing remote virtual care during the pandemic. In a few weeks, telehealth went from under 5% of patient visits to almost 93%, while maintaining high levels of patient satisfaction. In this paper, we share clinician recommendations and guidance gleaned from this transition to the frontweb and offer a systematic approach for ensuring "webside" success.

Leveraging Electronic Consultations to Address Severe Subspecialty Care Access Gaps in Nigeria.

Nigeria, Africa's most populous nation, is experiencing a dire challenge in meeting the specialty care access needs for its people, with extremely limited capacity to deliver subspecialty healthcare. Telemedicine/telehealth has been offered as a part of the solution to resolve health inequities, maldistribution and "brain drain" for health care services. In this preliminary communication, we assessed the impact of a telehealth innovation, subspecialty clinician-to-clinician electronic consultations (eConsult), on general practitioners (GPs) serving a diverse patient population in Nigeria. We found high levels of utilization of the eConsult platform by Nigerian physicians for a variety of cases and subspecialties. The most commonly used specialties were Obstetrics/Gynecology, Pediatric specialties and subspecialties, and Dermatology. Nigerian GPs spent more time generating and submitting their eConsults than American counterparts, but high levels of physician satisfaction and education from the eConsults. GPs reported the reduction in unnecessary services and improved care plans in the majority of cases, suggesting the tremendous potential for eConsults to build capacity for clinicians in nations where subspecialty care services are scarce.

The Impact of the Patient-Centered Medical Home on Health Care Disparities: Exploring Stakeholder Perspectives on Current Standards and Future Directions.

Over the past decade, the Patient-Centered Medical Home (PCMH) has become a preeminent model for primary care delivery. Simultaneously, health care disparities have gained increasing attention. There has been limited research on whether and how the PCMH can or should affect health care disparities. The authors conducted qualitative interviews with key stakeholders and experts on the PCMH model and health care disparities, including grant and policy makers, accreditors, researchers, patient advocates, primary care practices, practice transformation organizations, and payers, to assess perspectives on the role of the PCMH in addressing health care disparities. The application of grounded theory and thematic analysis elucidated best practice recommendations for the PCMH model's role in addressing health care disparities. Although the majority of stakeholders support greater integration of efforts to reduce health care disparities into the PCMH model, most stakeholders view the current PCMH model as having minimal or indirect influence on health care disparities. The majority supported greater integration of efforts to reduce health care disparities into the PCMH model. As the PCMH model continues to be refined, and as the health care system strives toward improving population health, there must be reflection on the policies and delivery systems that impact health care disparities.

Electronic consultation impact from the primary care clinician perspective: Outcomes from a national sample.

INTRODUCTION: Electronic consultations (eConsults) provide asynchronous, store-and-forward communication between primary care clinicians (PCCs) and specialists using web-based platforms, electronic health records or mobile applications. eConsults have demonstrated benefits in many areas of the Quadruple Aim, including educational value for PCCs. In this study, we explored the connection between eConsults and the Quadruple Aim using a unique national dataset of PCC-reported eConsult outcomes. METHODS: We conducted a retrospective study analysing registry data from the RubiconMD electronic consultation platform used by PCCs in 34 US states. We analysed PCC-reported outcomes from eConsults that took place between March 2017 and January 2018. PCCs were asked to select one or more of the following options after each eConsult: improved care plan, educational, avoided unnecessary diagnostics/procedures, avoided referral altogether or to wrong specialty, or no effect. RESULTS: PCCs reported an outcome for 3872 eConsults. eConsults for dermatology, endocrinology, and haematology-oncology were most common. Over one in four PCCs reported that the eConsult avoided a referral altogether or to the wrong specialty (26.3%) and avoided unnecessary diagnostics/procedures (26.1%). In 75% of eConsults, PCCs reported an improved care plan. Fifty percent reported that the eConsult was educational. DISCUSSION: PCCs in diverse practice settings reported substantial benefits from eConsults. In over half of eConsults, PCCs reported that the eConsult avoided unnecessary diagnostics/procedures, avoided a referral altogether or avoided a referral to the wrong specialty. Findings suggest that eConsults demonstrate important educational benefits, but may also influence PCC decision-making in a way that yields tremendous cost-saving potential and improved patient experience.

Physician Burnout and Higher Clinic Capacity to Address Patients' Social Needs.

BACKGROUND: A recent regional study found lower burnout among primary care clinicians who perceived that their clinic had greater capacity to meet patients' social needs. We aimed to more comprehensively investigate the association between clinic capacity to address social needs and burnout by using national data that included a more representative sample of family physicians and a more comprehensive set of practice-level variables that are potential confounders of an association between clinic social needs capacity and burnout. METHODS: We conducted a cross-sectional analysis of 1298 family physicians in ambulatory primary care settings who applied to continue certification with the American Board of Family Medicine in 2016. Logistic regression was used to test associations between physician and clinic characteristics, perceived clinic social needs capacity, and burnout. RESULTS: A total of 27% of family physicians reported burnout. Physicians with a high perception of their clinic's ability to meet patients' social needs were less likely to report burnout (adjusted odds ratio [OR], 0.66; 95% confidence interval [CI], 0.47-0.91). Physicians who reported high clinic capacity to address patients' social needs were more likely to report having a social worker (adjusted OR, 2.16; 95% CI, 1.44-3.26) or pharmacist (adjusted OR, 1.73; 95% CI, 1.18-2.53) on their care team and working in a patient-centered medical home (adjusted OR, 1.65; 95% CI, 1.24-2.21). CONCLUSION: Efforts to reduce primary care physician burnout may be furthered by addressing structural issues, such as improving capacity to respond to patients' social needs in addition to targeting other modifiable burnout risks.

Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim.

A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.

Electronic consultation system demonstrates educational benefit for primary care providers.

Background Electronic consultation systems allow primary care providers to receive timely speciality expertise via iterative electronic communication. The use of such systems is expanding across the USA with well-documented high levels of user satisfaction. We characterise the educational impact for primary care providers of a long-standing integrated electronic consultation and referral system. Methods Primary care providers' perceptions of the educational value inherent to electronic consultation system communication and the impact on their ability to manage common speciality clinical conditions and questions were examined by electronic survey using five-point Likert scales. Differences in primary care providers' perceptions were examined overall and by primary care providers' speciality, provider type and years of experience. Results Among 221 primary care provider participants (35% response rate), 83.9% agreed or strongly agreed that the integrated electronic consultation and referral system provided educational value. There were no significant differences in educational value reported by provider type (attending physician, mid-level provider, or trainee physician), primary care providers' speciality, or years of experience. Perceived benefit of the electronic consultation and referral system in clinical management appeared stronger for laboratory-based conditions (i.e. subclinical hypothyroidism) than more diffuse conditions (i.e. abdominal pain). Nurse practitioners/physician assistants and trainee physicians were more likely to report improved abilities to manage specific clinical conditions when using the electronic consultation and/or referral system than were attending physicians, as were primary care providers with ≤10 years experience, versus those with >20 years of experience. Conclusions Primary care providers report overwhelmingly positive perceptions of the educational value of an integrated electronic consultation and referral system. Nurse practitioners, physician assistants, trainee physicians and less-experienced primary care providers report the greatest clinical educational benefit, particularly for conditions involving lab-based diagnosis and management.