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Table 2 Key themes and supporting quotes

From: Expect delays: poor connections between rural and urban health systems challenge multidisciplinary care for rural Americans with diabetic foot ulcers

ThemeSupporting quotes
Rural PCP- rural specialist collaboration facilitated by professional connections“In a small hospital, you know who the wound care nurse is. You can just call them up or email to touch base, or I’ll just stop by.” Rural diabetes educator
“When I take off somebody’s shoe and see bone, I just walk over to the podiatrist and say, ‘Could you come take a look?’”Rural PCP
“I’m fortunate to be good friends with one of the orthopedic surgeons here. If I feel like somebody needs to be seen quickly, I just call him up and he’s very good about that kind of stuff. The podiatrist we used to have in town was super about seeing people the same day.” Rural PCP
Time consuming referrals“A few years ago, the patient would walk out the door with a [specialty] appointment in hand, which I think is better. Now they have to call up some referral coordinator and then it gets computerized somehow, and then the computer sends it, and somebody from the specialty clinic ends up calling the patient if their insurance is good enough and all that stuff is approved.” Rural PCP
“It’s become a little bit more challenging over the last few years. Years ago. .. we used to make the appointments ourselves. Now we have another step where we have a referral department, which helps determine things like, ‘This person has this type of insurance. They need to go here.’ Sometimes the process takes longer. You can’t call [a tertiary care hospital] anymore and say, ‘Hey I have this patient.. .’ You’ve got to send information, and they triage it. The process takes longer than it used to.” Rural PCP
“The case manager is responsible for making sure that the physician order got entered for the referral and then we route the task to our receptionist. She processes it. She faxes the referral order and the physician’s notes and the imaging. We put that all in the referral order.. . Then she sends a face sheet and the referral order to the specialty provider, and she just puts on the cover sheet, ‘Please contact patient to schedule.’”Rural administrative support staff
“It is time consuming to get the records. Sometimes the medical records departments at the other healthcare facilities don’t know exactly what we want. We have to be very specific with what we want.” Urban administrative support staff
“By the time they come to us, they’re already at quite an advanced stage. So if we wait for those referrals to happen from the primary care provider and go through insurance coverage and this and that. . . There’s just too many loopholes.” Urban infectious disease physician
Negative experiences calling urban specialists“I typically like to have all my ducks in a row before I call a specialist because I feel like family doctors are not really all that highly respected amongst the medical field.” Rural PCP
“Doctors sometimes eat their young. Sometimes they are awfully critical of what others are doing.” Rural PCP
Multiple EHRs as a barrier to data sharing“Somebody may have had a lab drawn in a different system. .. but I might not take the time to look because it would be a lot of work. It would be nice if lab and imaging results showed up in our EHR from other systems. It’s one of my biggest gripes. You can access results, but it would be nice if they just showed up automatically.” Rural PCP
“We have different electronic medical records. We get patients from all over. Trying to gather all that information- I’m surprised these nurses have any hair left on their heads after trying to organize that stuff.” Rural wound care provider
“Sometimes there are things in [the system that links two EHRs] that we cannot see, even though it will be in the system.” Urban administrative support staff
“With the different places I go, there are different electronic medical records. Typically, I will look through to find as much information as I can on the patient before going to see them.. . Sometimes it’s very difficult.” Urban vascular surgeon who does rural outreach
The value of multidisciplinary care and teamwork“The team is what makes us work. It can work just as well in a rural community as it does in the city, and I think it is maybe even more important.” Rural wound care provider
“It is absolutely essential to try and conform our management plan within the realm of local resources. That’s very important― to have the local communities be part of the team.. . All of us have a role to play and something to contribute.” Urban infectious disease specialist