UMMS Affiliation

Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences

Publication Date


Document Type



Health Information Technology | Health Services Administration | Health Services Research | Military and Veterans Studies | Telemedicine


OBJECTIVE: To explore Veterans Health Administration clinicians' perspectives on the idea of redesigning electronic consultation (e-consult) delivery in line with a hub-and-spoke (centralized) model.

MATERIALS AND METHODS: We conducted a qualitative study in VA New England Healthcare System (VISN 1). Semi-structured phone interviews were conducted with 35 primary care providers and 38 specialty care providers, including 13 clinical leaders, at 6 VISN 1 sites varying in size, specialist availability, and e-consult volume. Interviews included exploration of the hub-and-spoke (centralized) e-consult model as a system redesign option. Qualitative content analysis procedures were applied to identify and describe salient categories.

RESULTS: Participants saw several potential benefits to scaling up e-consult delivery from a decentralized model to a hub-and-spoke model, including expanded access to specialist expertise and increased timeliness of e-consult responses. Concerns included differences in resource availability and management styles between sites, anticipated disruption to working relationships, lack of incentives for central e-consultants, dedicated staff's burnout and fatigue, technological challenges, and lack of motivation for change.

DISCUSSION: Based on a case study from one of the largest integrated healthcare systems in the United States, our work identifies novel concerns and offers insights for healthcare organizations contemplating a scale-up of their e-consult systems.

CONCLUSIONS: Scaling up e-consults in line with the hub-and-spoke model may help pave the way for a centralized and efficient approach to care delivery, but the success of this transformation will depend on healthcare systems' ability to evaluate and address barriers to leveraging economies of scale for e-consults. Informatics Association 2021. This work is written by US Government employees and is in the public domain in the US.


electronic health records, integrated delivery of healthcare, qualitative research, Veterans health services, remote consultation

Rights and Permissions

Published by Oxford University Press on behalf of the American Medical Informatics Association 2021. This work is written by US Government employees and is in the public domain in the US.

DOI of Published Version



Anderson E, Rinne ST, Orlander JD, Cutrona SL, Strymish JL, Vimalananda VG. Electronic consultations and economies of scale: a qualitative study of clinician perspectives on scaling up e-consult delivery. J Am Med Inform Assoc. 2021 Sep 18;28(10):2165-2175. doi: 10.1093/jamia/ocab139. PMID: 34338797; PMCID: PMC8449629. Link to article on publisher's site

Journal/Book/Conference Title

Journal of the American Medical Informatics Association : JAMIA

PubMed ID


Related Resources

Link to Article in PubMed