Barriers and Benefits of the Scheduled Telephone Referral Model (DETELPROG): A Qualitative Approach

International Journal of Environmental Research and Public Health Article Barriers and Benefits of the Scheduled Telephone Referral Model (DETELPROG): A Qualitative Approach Luis Miguel Azogil-López 1,2 , Valle Coronado-Vázquez 3,4 , Juan JoséPérez-Lázaro 5, Juan Gómez-Salgado 6,7,* and Esther María Medrano-Sánchez 8,*   Citation: Azogil-López, L.M.; Coronado-Vázquez, V.; Pérez-Lázaro, J.J.; Gómez-Salgado, J.; Medrano-Sánchez, E.M. Barriers and Benefits of the Scheduled Telephone Referral Model (DETELPROG): A Qualitative Approach. Int. J. Environ. Res. Public Health 2021,18, 5280. https://doi.org/10.3390/ ijerph18105280 Academic Editor: John Øvretveit Received: 18 March 2021 Accepted: 13 May 2021 Published: 16 May 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1Health Service of Andalusia, Primary Health Center Bollullos de la Mitación, 41110 Seville, Spain; [email protected] 2Rural Medicine Group, Andalusian Society of Family and Community Medicine (SAMFyC), 18001 Granada, Spain 3Health Service of Castilla La Mancha, Primary Health Center Illescas, 45200 Toledo, Spain; [email protected] 4Department of Health Sciences, “Santa Teresa de Jesús” Catholic University of Avila, 05005 Ávila, Spain 5Andalusian School of Public Health, 18080 Granada, Spain; [email protected] 6Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, 21007 Huelva, Spain 7Safety and Health Postgraduate Program, Universidad Espíritu Santo, Guayaquil 091650, Ecuador 8Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla, 41013 Sevilla, Spain *Correspondence: [email protected] (J.G.-S.); [email protected] (E.M.M.-S.); Tel.: +34-959219700 (J.G.-S.); +34-954486521 (E.M.M.-S.) Abstract: The recently developed scheduled mobile-telephone referral model (DETELPROG) has achieved especially important results in reducing waiting days for patients, but it has been decided to explore what barriers and positive aspects were detected by both primary care physicians (PCPs) and hospital attending physicians (HAPs) regarding its use. For this, a qualitative descriptive study was carried out through six semi-structured interviews and two focus groups in a sample of eleven PCPs and five HAPs. Interviews were carried out from September 2019 to February 2020. Data were analysed by creating the initial categories, recording the sessions, transcribing the information, by doing a comprehensive reading of the texts obtained, and analysing the contents. The results show that DETELPROG gives the PCP greater prominence as a patient’s health coordinator by improving their relationship and patient safety; it also improves the relationship between PCP and HAP, avoiding unnecessary face-to-face referrals and providing safety to the PCP when making decisions. The barriers for DETELPROG to be used by PCP were defensive medicine, patients’ skepticism in DETELPROG, healthcare burden, and inability to focus on the patient or interpret a sign, symptom, or diagnostic test. For HAP, the barriers were lack of confidence in the PCP and complexity of the patient. As a conclusion, DETELPROG referral model provides a lot of advantages and does not pose any new barrier to face-to-face referral or other non-face-to-face referral models, so it should be implemented in primary care. Keywords: qualitative research; referral; electronic consultation; telemedicine; primary care; waiting lists; patient safety; quality of healthcare; primary care physicians; hospital attending physicians 1. Introduction The DETELPROG (“Scheduled Telephone Referral”, from its acronym in Spanish) is a referral model that improves patients’ waiting times and unnecessary commuting with respect to face-to-face referral. It also considerably decreases waiting days for the resolution of the process through which the patient was referred to hospital, avoiding second face-to- face consultation with the hospital physician in almost all cases [ 1 , 2 ]. The evolution of this sophisticated and protocolised health attention model requires greater involvement and prominence of both primary care physicians (PCPs; Médicos de Atención Primaria—Spanish Int. J. Environ. Res. Public Health 2021,18, 5280. https://doi.org/10.3390/ijerph18105280 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021,18, 5280 2 of 16 acronym MAP) and hospital attending physicians (HAP; Médicos de Atención Hospitalaria or Internistas—Spanish acronym MI), who should function to support primary care and not as a distinct level of healthcare [ 3 ]. Countries with prioritised primary care investments are better prepared to achieve sustainable development goals than those with hospitalcentred systems [ 4 ]. This need has already been perceived by the Spanish government and the regional government of Andalusia, where our research project is developed, creating two strategic plans to strengthen primary care health attention within the public health system. In this coordination between rural or urban health centres and hospitals, the development of information and communication technologies is fundamental [5,6]. For the coordination between primary care and hospital care, there is strong evidence in favour of electronic referral interventions and interventions that include consultations with specialists prior to referral [ 7 ], which improve the problem of waiting lists for specialised consultations that are of so great concern in a large number of developed countries [ 8 – 11 ], and of course in Spain, where the waiting time average is 88 days [ 12 ], being this the main problem perceived by citizens regarding the health system [ 13 ]. The information and communication technologies implemented for this need can be classified into secure virtual asynchronous consultation platforms between primary care and hospital care (e-consultation), real-time mobile-phone consultations (curbside consultation), and scheduled mobile-phone or video conferencing consultations. E-Consultations are platforms that have been widely developed in many countries [ 7 – 11 , 14 – 27 ] with a positive impact on accessibility, avoidance of unnecessary commuting and consultation, waiting times, training of professionals, communication and interprofessional information, acceptability, cost, and satisfaction of patients and professionals, although there are few data on morbidity and mortality [8,14,27]. As barriers, e-consultations require significant technological changes, investment, institutional involvement, leadership, and unpaid work burden for professionals. In addition, there are legal doubts about liability among professionals, occasional delays in receiving responses, and difficulties in monitoring patients and convincing managers and physicians to implement and use, respectively, e-consultation [21,22,26]. On the other hand, real-time mobile-phone consultations (curbside consultation) are a common practice in which benefits are obtained in waiting times, decreased face-to-face appointments in specialised consultation, and patient and professional satisfaction [ 3 ]; but also serious communication problems, incomplete or fragmented information, difficulty choosing the colleague to consult, unpredictable interruptions with unscheduled time expense, etc., usually related to the unschedulable aspect of such queries [28–34]. Finally, scheduled mobile-phone or videoconferencing consultations have generally been implemented in rural areas where patients have significant accessibility issues to hospital care consultations. In this sense, they are similar to traditional face-to-face consultations regarding clinical efficacy [ 35 ], and also share benefits, without sharing barriers, with the above consultation methods [ 1 , 2 , 36 ]. However, they do require expensive technology and there are still few studies on this matter, especially in the field of psychiatry. The research team developed the DETELPROG, which achieved very important results in reducing waiting days for patients. However, on the other hand, it is surprising the low utilisation of this new referral model by PCP [ 1 , 2 ]. As a result, it has been decided to explore, through qualitative methodology, what barriers and positive aspects were detected by both PCP and HAP regarding the use of DETELPROG referral with the aim of finding areas of improvement and aspects to enhance in a possible, more widespread implementation in a rural health area or in other related areas. Int. J. Environ. Res. Public Health 2021,18, 5280 3 of 16 2. Materials and Methods 2.1. Design Qualitative descriptive study where a semantic content analysis was performed through six semi-structured interviews and two focus groups. 2.2. Study Population The study population was a finite population made up of the five HAPs who provided consultation at the Rio Tinto hospital (the internal medicine service consists of seven HAPs in total) and the 13 PCP who formed the pilot group of the DETELPROG study [ 1 , 2 ], who had the possibility of receiving or performing scheduled mobile-phone referrals during the study period (there are 58 PCP with medical quota in the health area). The group of five HAPs was composed of two key informants, who were interviewed through a semi-structured interview, and three HAPs in the focal group. Of the 13 PCP, two of them were discarded from the study because they did not need to perform any referral to internal medicine in either period of the study, resulting in 11 PCPs (two key informants who were interviewed through a semi-structured interview, adding to the nine PCP in the focal group). Figure 1shows the randomised selection process of PCP at the start of the DETELPROG project [1,2]. Figure 1. Primary Care Physicians’ sampling selection scheme of the DETELPROG study [ 1 , 2 ]. PCP: Primary Care Physicians. The sociodemographic variables of the sample are found in Table 1. There were three women and two men in the HAP group, aged between 45 and 67 years (median = 60; mean = 57.4; SD = 9.2). Two of the HAPs had worked as PCPs at the beginning of their working lives. As for the years of work experience, they had worked between 19 and 41 years, with a median of 37 years. With respect to PCPs, six of them were women and seven were men, aged between 37 and 66 years (median = 60; mean = 54.55; SD = 10.76). Int. J. Environ. Res. Public Health 2021,18, 5280 4 of 16 Table 1. Sociodemographic characteristics of sample. Sociodemographic Characteristics PCP (n = 11) HAP (n = 5) Sex n (%) Male Female 5 (45.45%) 6 (54.55%) 3 (60%) 2 (40%) Age in years Minimum-Maximum Mean (CI 95%) 37–66 54.55 (47.31-61.78) 45–67 57.4 (46–68.8) Work experience in years Minimum-Maximum Mean (CI 95%) 8–36 22.27 (15.97–28.58) 19–41 32 (20.22–43.78) Years in the same office at the beginning of the DETELPROG Minimum-Maximum Mean (CI 95%) 0–36 8.64 (1.34–15.93) 1–30 15.20 (1.73–28.67) Distance to hospital in kilometres Minimum-Maximum Mean (CI 95%) 36 (±11) - Number of healthcare cards adjusted by age Minimum-Maximum Mean (CI 95%) 845–2679 1.756 (1330–2181) - Number of referrals in 2014 Minimum-Maximum Mean (CI 95%) 7–59 32.45 (20.62–44.29) - Rurality index Minimum-Maximum Mean (CI 95%) −1.09/−0.1 −0.60 (−0.86/−0.32) - CI: confidence interval; HAP: hospital attending physician; PCP: primary care physician. 2.3. Selection of Participants •Inclusion criteria: Being a finite and accessible population, the study was carried out with all the members of the study population who wished to participate in it. • Exclusion criteria: those PCP and HAP who did not participate in the DETELPROG study or any referral process. • Key informants: They are participants who, due to the following characteristics, are interesting enough to have their opinions analysed through a semi-structured interview in a deeper way. o Key informant PCP 1: the PCP that most rejected DETELPROG (21 rejections of 36 referrals). o Key informant PCP 2: the PCP that least rejected DETELPRG (0 rejections of 14 referrals). o Key informant HAP 1 and 2: two HAP who had worked in primary care as PCP years earlier were selected for their dual perspective. 2.4. Data Collection A focus group was created for PCPs (nine participants) and another one for HAPs (three participants). Subsequently, four semi-structured interviews were done with the key informants, two with the PCP key informants, and two with the HAP key informants. Recordings were made from 3 September 2019, when the PCP focus group was created, to 28 February 2020. The interviewer-moderator, in all cases, was the main researcher, workmate PCP of all the participants. An observer was also used for nonverbal language annotation for the focus groups. Int. J. Environ. Res. Public Health 2021,18, 5280 5 of 16 Prior to the call and with the aim of not disregarding any barriers or benefits detected by the interviewees, researchers agreed to develop an interview script (see Files S1 and S2) asking about DETELPROG’s barriers and benefits as compared to face-to-face referral, at each stage of the interview (from the PCP’s referral to discharge by the HAP), and also taking into account the problems identified in studies on other non-face-to-face referral models found in the literature review. 2.5. Barriers in Data Collection For the organisation of the PCP focus group, many difficulties arose for the call, but we managed to summon the participants in a restaurant located at equidistant distance from the work centres of the PCPs, and the recording was made at the beginning of the meal. For the organisation of the HAP focus group, participants preferred to make the recording in the meeting room of their service without any convening problems. The last 5 min were not recorded because the memory of the recorder got full, and it stopped recording. To solve this setback and because both the interviewer and the observer agreed that there was no relevant information in those unrecorded minutes, (the problem was detected within few minutes of finishing the focus group interviews), it was decided not to incorporate anything else into the transcription of the recorded audio. Individual interviews were conducted without any problems, by appointment, at the place and time proposed by the interviewee. To perform semantic analyses, the main researcher had to be trained in the use of Nvivo version 12 software (QSR International, Melbourne, Australia) and then, train two other members of the group to make a correct triangulation when the time of analysis came. For the agreement, when establishing the final categories, the unanimous agreement was always reached for the designation of the category and for its definition. The agreement was also sought, at least by two of the three researchers, for the encoding of the data and of removed data by the three researchers whenever they considered these not useful. 2.6. Data Analysis A content analysis of the collected data was carried out. Initially, the categories agreed by the research group and which emerged from the literature review were the following: oDecision making of the most appropriate type of referral. oInformed verbal and written consent. oTechnical and programme characteristics for the request of the first appointment. oCommunication with the HAP. oTechnical details (phone, computer, . . . ). oInterpersonal characteristics (decision making, attitudes, . . . ). oPatient follow-up. oPCP-Patient relationship. oPCP-HAP relationship. The subsequent process was carried out: • Recording: interviews and focus groups were recorded in digital format with prior informed consent of the participants. • Transcript: all recorded data were literally transcribed into a writting computerised processor. • Comprehensive reading of texts: once the recordings were transcribed, a preliminary reading of these texts was made to correct transcription errors. •Analysis of the contents: a semantic analysis was carried out in two phases: 1) Identification of relevant segments of the text (Encoding of transcriptions): Transcripts were encoded by 3 members of the research team, who subsequently agreed on the different categories and their final definitions (Table 2). 2) Profile analysis: Once the final categories were agreed and all recordings were transcribed, all transcripts were encoded and the transcription content analysis Int. J. Environ. Res. Public Health 2021,18, 5280 6 of 16 was performed by categories and divided by HAP and PCP profiles, with the help of the Nvivo 12 software (Table 3). Table 2. Final categories. Categories Definitions Primary Care Physicians as key axis Feeling of giving the PCP a more key role in decision-making regarding the health of their patients, even in the hospital environment Lack of available tests in primary care As a cause of the DETELPROG’s success is the scarce tests catalogue available for PC, that allows expanding when agreed with the Hospital Attending Physicians. Comparison with other types of referral Comments and comparisons with other types of already experienced PC-hospital referral/contact (face-to-face referral, mail, non-scheduled telephone consultation . . . ) General qualitative assessment General assessment and satisfaction of participants Proposals for improvement Proposals for improvements made by participants. Ethical-legal implications Doubts raised about ethical-legal issues Causes for refusing-accepting DETELPROG Patients and consultations characteristics, or any other type of characteristic that makes the PCP refuse DETELPROG or use it instead of face-to-face referral. Positive or negative characteristics regarding: PCP-HAP relationship Characteristics that modify the professional relationship between Primary Care Physicians and Hospital Attending Physicians Physician-patient relationship Characteristics affecting the PCP-patient relationship Planning DETELPROG Facilities or problems that have been raised since PCP considered referring the patient until the beginning of the telephone consultation (Planning suitability of the said referral method, informed consent of the patient, planning the day when the telephone consultation will take place, planning the telephone consultation with their workmate). Quantitative improvements Improvement of quantitative variables: waiting times, commuting, waiting lists, capacity to assist more/less patients. Communication PCP-HAP-patient Benefits and problems in telephone communication between PCP-HAP-patient (attitudes, agreement and disagreement on complementary tests, treatment, follow-up, revision, advice, quality of information, reliability of information, information record). Organisational characteristics Any characteristic that depends on DETELPROG organisation (initial training phase/prior preparation of participants, schedule organisation -time and duration-, work overburden, consultation protocolisation . . . ). Technical characteristics Telephone performance, computer and software performance (access to patients’ medical history, complementary tests, consultation mode . . . ) HAP: hospital attending physician; PCP: primary care physician. Int. J. Environ. Res. Public Health 2021,18, 5280 7 of 16 Table 3. Verbatim quote table per categories. Category Verbatim 1. Primary Care Physicians as key axis “ . . . the family physician increases his or her importance, his or her relevant role, increases decision-making; and, in the end, increases everything by, somehow, assuming more responsibility, though this was advised, agreed, etc., but the family physician becomes an even more relevant key axis in health care . . . ” (key informant HAP 1) 2. Lack of available tests in primary care “ . . . Before HAP, I was a general physician here in Huelva and my training had dealt with hospital care right after finishing my degree, and I properly knew what to do. The thing is, I didn’t have the appropriate means. So, I suppose . . . that would be the issue, knowing what to do but having no means available . . . (key informant HAP 2) “ . . . and then, something basic has been achieved, that is avoiding one step if we, primary care physicians, had the chance to request those complementary tests, more than 90% would be avoided...” (PCP focal group) 3. Comparison with other types of referral 3.1 Immediate telephone call “it was a somehow simpler consultation; I would say ‘I’ll request the CAT scan’, and then I would write: ‘The family physician is requesting a CAT scan, I find no contraindications so, I accept’, and everything was somewhat less informed because the family physician requested I prescribed a CAT scan, and the information I received was more or less sensible so I agreed but, well . . . ” (HAP key informant 1) 3.2 E-consultation “ . . . it has been a long wait because one doesn’t know whether the person is available, maybe on holidays, or off-work or on leave . . . This happened to me, and then, I received the answer a month later. Also, you don’t feel so much at ease; the questions you may be asked by the specialist regarding the patient, maybe through an online question I write a series of data but there are still some missing that, in face-to-face communication, I would be able to better clarify . . . ” (PCP) 4. General qualitative assessment “My subjective feeling and that of my patients, which I can communicate to this group, is that it has been a highly positive experience, that is, the patient, as the introduction says, has had improvements in terms of time; he/she has been assisted earlier, has gained in comfortability, not only thanks to avoiding commuting to hospital, but also because the first consultation has been done in front of their family physician, who usually holds a much more intimate relationship with the patient than other specialists they don’t know”. (PCP focal group) “Very useful. I think this is already assumed; it is much more convenient and I would like this type of systems to be implemented. I feel more confident and at ease when contacting that person, having direct contact”. (PCP) “I serve as support, a good one that must be regarded as positive because this supportive element may save lives, but in certain circumstances, on the contrary, you may have overseen some issue and the patient would have benefited more from a face-to-face consultation despite this being a month and a half later in time; we must also be aware of this . . . ” (HAP key informant 1) 5. Ethical-legal implications “when you refer somebody to hospital, it is like you are getting rid of them, and then the hospital “internist” or specialist is in charge of their health or of that specific problem the patient has. However, this way, well, you can share the patient and the internist is not the sole responsible, but you are instead”. (PCP key informant 2) “ . . . the responsibility is shared, and I’ll let you know why: from the very moment you start telling a hospital specialist about the patient, their history, medication and physical exploration, if that physician does not want to take care of the patient, he/she says, look, this patient . . . ” (PCP focal group) “I must confess that, when this happened, I would say: ‘virtual consultation’, so that later on the fact that I didn’t physically see the patient would be known, that it was a telephone consultation and I had followed what my colleague from PC said, so it is true that I tended to say ‘better safe than sorry’, look, I did what I could by telephone . . . ”. (HAP focal group) “so, obviously, there is a responsibility on the part of PCP, as I was saying, to accept these tests for their patient, but also, there is written responsibility that I requested the test so, if something goes wrong, if there is any negative effect, and the patient demands some explanation, this will go to the physician who requested the test, who hasn’t spoke to the patient, doesn’t know the patient . . . ” (HAP key informant 1) Int. J. Environ. Res. Public Health 2021,18, 5280 8 of 16 Table 3. Cont. Category Verbatim 6. PCPHAP relationship “E3: It is not significant. The volume of consultations was not significant for that . . . E2: It was irregular”. (HAP focal group). “I think so, I think this strengthens the relationship, for example, physician Morales I didn’t know her, and she is so kind and collaborative in every way, and I believe this strengthens the relationship, sure”. (PCP) 7. Physician-patient relationship “ . . . when answering a telephone consultation, obviously, you cannot see the patient, that is completely out of sight to favour diagnostic speed, which is the actual interest, helping the patient as swiftly as possible . . . ” (HAP key informant 1) “ . . . it was like patients regarded you as something important, that is, as if in hospital you were more valuable and they agreed on opinions that had already been expressed to the patient and on which internists also agreed . . . What I experienced was an important improvement of the physician-patient relationship”. (PCP key informant 2) 8. Planning DETELPROG “That is the only thing to change, some appointments, because they were finishing their on-call or they coincided with the specialist’s, which had been on-call as well. That is the only occasion in which we have had to change any appointment . . . In general, everything was properly done”. (PCP) “No, no. I believe I have a certain amount of experience at the clinical level and, overall, I am able to identify pathologies and solve the issue but, no, for instance, when you receive results and you have to analyse them and revise everything, yes . . . ” (HAP key informant 2) 9. Quantitative improvements “ . . . one thing has mainly been gained, that is avoiding a step if we, primary care physicians, had the chance to request those complementary tests, this would avoid more than 90%...” (PCP focal group) “ . . . everything was quite swiftly done . . . ”. (PCP key informant 2) 10. PCP-HAP-patient communication 10.1 Quality and quantity “I believe that the family physician is quite enriching as when a patient is referred, you are lacking some data and the family physician does know the patient and, even sometimes, their family interrelationship, so there is a bunch of data that are not usually reported through written means but which, at the communication level, are even much more enriching, I would even say that this previous contact is quite enriching”. (HAP key informant 1). “ . . . always, when talking to another person, be it even via phone call, communication is more fluent than what can be said in a written document, which is usually more objective information and, mainly because of time issues, also more limited”. (PCP key informant 1) 10.2 Reliability “You are not told about the patient the same way depending on who gives you the report. In the end, you opt for requesting an abdominal ultrasound and requesting a consultation”. (HAP focal group). “ . . . there is still a somehow uneasy feeling that I haven’t auscultated the patient, explored them, and I must only assume the data given by the PCP”. (HAP key informant 1) 10.3 Agreements “E3: This is positive as the first days I request, and then, ‘how do we do it?’, ‘wait till I get informed’, ‘I think I kept the colleague’s phone number and Mari Ángeles, the assistant . . . (agreement on that). E2: But well, we did it like that, the first ones we referred them to the family physician with the signature and then, the last ones, we signed them here. If anybody wanted a test request or whatever, you would do so, if it was a special coding, and the test would be sent from here and the ultrasound examinations requests were done through the X-rays department and the appointment was programmed as if it had been done face-to-face”. E3: A record is sent, as if the patient were face-to-face, their record . . . E1: this is why you didn’t encounter any problem, right? E3: No . . . E2: Each one gave their best, right. (HAP focal group) 10.4 Attitudes “ . . . at the beginning there were some physicians or internists who were not willing to collaborate much, and we all know who we are referring to. So, this is an issue, lack of collaboration . . . for me myself and my circumstances . . . ”. “Somehow sardonically they would say “virtual consultation” . . . At the beginning, internists were skeptical, that a secretary, a virtual model . . . It was not much heard at the moment but, little by little, they started taking it more seriously . . . ”. (PCP focal group) Int. J. Environ. Res. Public Health 2021,18, 5280 9 of 16 Table 3. Cont. Category Verbatim 11. Organisational characteristics 11.1 Preparation phase “E3: . . . with the problem that you don’t know the interlocutor you are talking to, one gives it for granted that we, physicians, all have the same training . . . E1: that is questionable. E3: Well, that is why it also depends on who is talking to you in the interconsultation . . . ” (HAP focal group) 11.2 Telephone consultation schedule “Sometimes it occurred . . . that nobody answered the phone and the patient needed to go out of the office and wait for some minutes and, then, a quarter of an hour later while I was receiving other patients, we tried again and they answered . . . no appointment had to be canceled, it just took a bit longer . . . I received some more patients and, at the second try, it was solved”. (PCP key informant 1) 11.3 Time set for consultation “As for the consultation times, it was 15 min; do you find it appropriate? “Yes, yes, absolutely”. (PCP key informant 1) 11.4 PCP work overburden “maybe a bit of overburden for us who, instead of passing the patient over, we need to be more present and aware of what is happening in the medical history but, well, this is our job and what I like doing so, this overburden is not such . . . ” (PCP key informant 2) 11.5 Prior protocols “ . . . it would be to, somehow, establish the assessment of, somehow, how to put everything together, all the available means and everything we can do to reach a consensus, that is, an appropriate method. Establishing protocols”. (HAP key informant 2) 12. Technical characteristics “E1: Did you find any problem with telephone communication at the technological level, other from the one we already identified? E3: What I said before about changing room to answer the phone, but it was eventually solved . . . E2: no, no . . . ”. (HAP focal group) 13.Causes for refusing-accepting DETELPROG 13.1 Accepting “This is for standard and easy issues, telephone consultation. For very specific minor issues.” (HAP focal group) “PCP-HAP communication, I believe there would be no a priori limitations. I think that updated and live communication where the family physician explains to the specialist the patient’s circumstance, a priori, the patient’s characteristics may not imply any limitation to reject the telephone consultation”. (HAP key informant 1) “I don’t think so, as telephone communication is simple and direct, and the patient may even be prevented from having to commute to hospital and, if the patient trusts the assisting physician, they will absolutely delegate to him/her”. (PCP key informant 1) 13.2 Refusing 13.2.1 HAP “You are not told about the patient in the same way, depending on the physician, and this is highly influential. You eventually end up requesting an abdominal ultrasound and setting an appointment”. “Older more complex patients or not so old but complex imply many nuances that are difficult to solve in a consultation, difficult to leave it solved, or I find it difficult unless both the PC physician and the specialist know the patient, that both know what the issue is about . . . that way, it could be possible”. “if I don’t know the patient’s issue, I don’t know how to explain if this is a bruise, or Velcro, or crackles. So, this must be seen by the internist . . . or if it is a skin condition whose origin I don’t identify and may be related to a more general disease . . . ”. (PCP) 13.2.2 PCP “If I don’t know the patient’s issue, I don’t know how to explain if this is a bruise, or Velcro, or crackles. So, this must be seen by the internist . . . or if it is a skin condition whose origin I don’t identify and may be related to any more general disease . . . ”. (PCP) “In some odd case with a patient, being critical of myself, maybe due to my own feeling of responsibility, I think, I will make a mistake, not meet expectations . . . ”. (PCP focal group) “Due to the shortage of time we’ve got, we don’t get rid of the patient because, the good point of referral is that you say ‘I’ll refer you to internal medicine, and they’ll take care of you, one less issue to care about, because I don’t have more time but, well . . . The downside would be that one, it is extra work added to what already is a quite complex schedule and agenda regarding times”. (PCP key informant 1) HAP: hospital attending physician; PCP: primary care physician. Int. J. Environ. Res. Public Health 2021,18, 5280 16 of 16 23. Van Der Velden, T.; Schalk, B.W.M.; Harmsen, M.; Adriaansens, G.; Schermer, T.R.; Ten Dam, M.A. Implementation of webbased hospital specialist consultations to improve quality and expediency of general practitioners’ care: A feasibility study. BMC Fam. 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