"I Am Reluctant to Continue, Yet Know She Could Go into Withdrawal": A Qualitative Analysis of Clinician Requests for eConsults in Opioid Management in the Ambulatory Setting.

Background: Electronic consultations (eConsults) allow clinicians to submit questions through the electronic health records (EHR) to request specialist input about individual patients' care, but there is paucity of literature describing eConsult programs specifically for opioid management.

Objectives: 1. To understand clinicians' reasons for seeking eConsults for opioid management. 2. To describe characteristics of clinicians' questions that can be addressed through eConsults without requiring in-person specialist visits.

Design: Retrospective qualitative study of eConsults for opioid management in the ambulatory setting.

Participants: Clinicians who submitted an eConsult request for opioid management.

Approach: We conducted a qualitative content analysis of eConsult requests and responses. First, a priori codes were developed and applied to textual data. Through iterative discussion and memoing, thematic codes were identified and applied to the dataset. Subsequently, breadth and depth of codes were explored, collapsed, and redefined, and relationships between codes were discussed. Following theme development, matrix analysis was used to compare eConsults that resulted with or without a recommendation for an in-person specialist visit.

Key results: Forty eConsults were requested by 30 unique referring clinicians mostly from general internal medicine (53%) or family medicine (27%). We identified four themes: (1) clinicians were motivated to reduce harm, (2) clinicians had difficulty labeling opioid misuse and use disorder (OUD), (3) clinicians had difficulty articulating discrete questions, and (4) clinician questions revealed knowledge gaps in opioid management. In-person specialist visits were recommended when clinicians needed help with labeling opioid misuse or OUD or when questions were vague and around complex topics.

Conclusion: Clinicians have unease and discomfort in treating chronic pain and managing opioids. eConsults are most helpful for low-complexity, discrete questions from clinicians focused on reducing harm. eConsult implementation should integrate EHR enhancements and clinician training in assessing opioid misuse and OUD and articulating discrete questions.