Table 2 What characteristics should a PC-SC communication tool have?

PC query handling

“You search for the specialty, you click and then you send it. You don’t need to have any personal contact to get someone to resolve it.” INT. 16 (PC physician, female).

“I tend to approach the people I work with more (…). I ask the people around me, I think it’s more immediate. I’m quite impatient, so I need immediate answers.” INT. 24 (PC nurse, female, non-user)

Type of information

“(The specialists) give you much more comprehensive information than they do when giving an immediate, off-the-cuff answer.” INT. 15 (PC physician, female)

“It is a reliable source because they are the go-to people.” INT. 19 (PC nurse, female)

“You may have the clinical practice guide and then you come across patients whose cases fall between the gaps in all of them. The fact that it’s a real patient (in ECOPIH) helps a lot because courses focus mostly on the topic, so then it’s quite hard to adapt it to specific cases that present in the surgery, such as patients with complex conditions. When it comes to providing care, they are real cases that you have to deal with and really need to consult on.” INT. 15 (PC physician, female)

Knowledge management

“What we need is a forum where we can discuss things; that would be the ideal clinical session, where you can sit down with your colleagues… that doesn’t happen, or happens very little in the teams. It was the type of tool I needed, that I’d been looking for, and it was good for me.” INT. 4 (PC director, male)

“When we call the hospital, they answer as fast as they can, as if you were bothering them.” INT. 15 (PC physician, male)

“Virtual consultation is convenient, provides an answer for that patient and is very powerful. But I still think that they are complementary tools for dealing with knowledge. If I put that query on ECOPIH, I’m asking a more generic question and will find a more generic answer that I can use for other patients too, and thousands of other colleagues of mine will also see it.” INT. 4 (PC director, female)

“ECOPIH is about building pillars for the future. The other system, virtual consultation, is about improving day-to-day management, the speed of action is much quicker at strategic management level. ECOPIH will give you that in the long term.” INT. 28 (PC director, male)

“We have quite a few clinical issues to resolve every day over the phone. If more people could see them, perhaps they wouldn’t need to ask about them again. There are many duplicate consultations. That’s the philosophy that needs to prevail.” INT. 2 (SC physician, male)

“It’s more enriching when everyone can see it, it’s much more enriching for me.” INT. 13 (PC physician, female)

“The larger the audience, the greater the fear of giving answers; some are undoubtedly a bit more defensive. It has an influence; it curbs the spontaneity that there would otherwise be in certain cases (…). I’m sure it has an influence, and a negative one in some cases.” INT. 8 (SC physician, male)

Cultural aspects

“(If ECOPIH had come from the hospital), it would have been used less. Because, if it comes from opposition rather than joint work, it is the hospital that puts its stamp of authority on it, while in primary care they act like automatons within models that may not be the best because there’s been no debate.” INT. 28 (PC director, male)

“If ECOPIH had come from the hospital, it would have been seen as something quite natural (by the specialists). Instead, it’s something that comes from below, from family doctors. It has created an attitude of anticipation rather than enthusiasm. (…). ECOPIH balances things out, that’s what technologies do, they are very democratic. Here, you treat specialists as equals, but that isn’t understood in the hospital. (…) It’s a change of role. (…) and there’s resistance to change.” INT. 3 (SC director, male)

“Above all, I think it’s an attitude of wanting to be more proactive, of shaking off your fears and wanting to do things differently.” INT. 2 (SC physician, male)

“I’d consult more often, but my feeling of embarrassment is quite intense. It’s an insurmountable embarrassment.” INT. 9 (PC physician, female)

“There aren’t enough nursing topics to consult on because, in nursing, you make your bed and you lie in it. Maybe the direction in nursing is the opposite. In medicine, questions are asked, and in nursing, maybe the experts should be the ones who present news so that people can be informed or debate can be generated.” INT. 23 (PC nurse, female)

“I find that some of the topics aren’t very specific, there are many medical things.” INT. 19 (PC nurse, female)

Technological aspects

“Access needs to be more direct. So that at the time when you have a query about a patient, when its fresh in your mind, you can make it more dynamic.” INT. 15 (PC physician, female)

“We did have some training, but when you start using it again, you forget what you’ve learned.” INT. 22 (PC nurse, male)

Organisational changes

“It’s something connected with work, but when you’re at work you can’t find the time to do it.” INT. 19 (PC nurse, female)

“It depends a lot on how you understand your profession. If you’re curious and need to increase your knowledge, you’ll use ECOPIH or you’ll study at home, you have to read, you need time.” INT. 4 (PC director, female)

“If you link it to senior management, you might undermine the tool to some extent because it is perceived as a form of managerial control. When MBO ends, the tool ends because there hasn’t been any personal motivation. It’s risky, it might by counterproductive for the tool.” INT. 28 (PC director, male)

“Recognition of the tool itself by provider companies is what’s missing; they need to integrate it into the initial visits. The two managers, of primary care and hospital care, need to sit down and decide what it means, how to recognise this work.” INT. 3 (SC director, male)

Legal liability

“I understand that it’s a secure tool. It doesn’t worry me, I do things that are much more insecure than this, for example, replying by e-mail, a telephone call… The thing here, though, is that it’s in writing, and it stays that way forever. The legal ramifications of this don’t worry me, but the very lack of definition of project makes me wonder: ‘Here, if I make a mistake and I receive a complaint about something I’ve said here, would the Catalan Health Institute consider it theirs?’.” INT. 3 (SC director, male)