Primary Care Provider Perceptions of Patient Engagement in an eReferral System: Lessons from a Safety Net System

Talk Code: 
J. Nwando Olayiwola
Margae Knox, MPH, Rachel Willard-Grace, MPH, Delphine Tuot, MDCM, MAS
Author institutions: 
University of California, San Francisco


eReferral is a HIPAA-compliant, electronic referral management and consultation system that has increased patient access to specialty care, optimized efficiency of the referral process, and enhanced primary care capacity for complex decision-making. However, at this time, patients are not included in the eReferral process and are largely unaware of it. We aimed to assess primary care provider (PCP) perceptions of potential new eReferral functions that could engage patients in the referral process, as well as anticipated benefits, drawbacks, and patient barriers.


We developed and administered an electronic survey to all PCPs in a county-based health system and a community clinic consortium in October 2015. Survey questions assessed PCP opinions of potential eReferral patient engagement functions primarily using 1-5 likert scales (“strongly agree to strongly disagree” or “great value to great detriment”). Open-ended questions inquiring about capabilities, benefits, drawbacks, and patient barriers were also included and analyzed qualitatively to complement findings from the more structured questions.


Thirty five percent of PCPs responded to the survey (n = 222). Overall, about half of PCPs (52%) supported patient and caregiver involvement in eReferrals in some capacity. In open-ended comments, PCPs commonly recommended adding scheduling-related capabilities such as ability for patients to schedule appointments, view appointments, and/or receive notifications when appointments are scheduled on their behalf. PCPs also recommended the ability for patients to view a referral status and message securely between patients and specialists.

Two-thirds of PCPs agreed/strongly agreed that greater patient engagement in eReferral would lead to more informed and activated patients. PCPs frequently expressed concerns about increased workload from patients’ engagement in eReferral (71% of PCPs agreed/strongly agreed and 53 open-ended comments). Although relatively few (32%) PCPs agreed/strongly agreed that patient or caregiver engagement in eReferral would increase medico-legal liability, open ended responses expressed concern about potential patient misunderstanding of referral content given their lack of medical knowledge and reduced openness between PCPs and specialists if patients could also see the correspondence. Most PCPs (76%) agreed/strongly agreed that involving patients or caregivers in the eReferral process would require significant training for patients/families. Barriers especially salient for underserved populations, identified through open ended comments, included language barriers for non-English speaking patients (n=72), low health literacy (n=59), and limited patient access to computers, phones, and the Internet (n=45).



Most PCPs report that patient engagement in the eReferral process would achieve important benefits like enhancing patient activation and reducing no-shows for specialist appointments. However, support for patient access to specific functions is mixed, and PCPs express concern about barriers to engagement, particularly for underserved patients.

Submitted by: 
J. Nwando Olayiwola
Funding acknowledgement: 
Blue Shield of California Foundation