Towards successful coordination of electronic health record based-referrals: a qualitative analysis

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Hysong, Sylvia J.
Esquivel, Adol
Sittig, Dean F.
Paul, Lindsey A.
Espadas, Donna
Singh, Simran
Singh, Hardeep

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Implementation Science


Background: Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may be challenging in the outpatient setting. Even when referrals are facilitated by electronic health records (EHRs) (i.e., e-referrals), lapses in patient follow-up might occur. Although compelling reasons exist why referral coordination should be improved, little is known about which elements of the complex referral coordination process should be targeted for improvement. Using Okhuysen and Bechky's coordination framework, this paper aims to understand the barriers, facilitators, and suggestions for improving communication and coordination of EHR-based referrals in an integrated healthcare system. Methods: We conducted a qualitative study to understand coordination breakdowns related to e-referrals in an integrated healthcare system and examined work-system factors that affect the timely receipt of subspecialty care. We conducted interviews with seven subject matter experts and six focus groups with a total of 30 PCPs and subspecialists at two tertiary care Department of Veterans Affairs (VA) medical centers. Using techniques from grounded theory and content analysis, we identified organizational themes that affected the referral process. Results: Four themes emerged: lack of an institutional referral policy, lack of standardization in certain referral procedures, ambiguity in roles and responsibilities, and inadequate resources to adapt and respond to referral requests effectively. Marked differences in PCPs' and subspecialists' communication styles and individual mental models of the referral processes likely precluded the development of a shared mental model to facilitate coordination and successful referral completion. Notably, very few barriers related to the EHR were reported. Conclusions: Despite facilitating information transfer between PCPs and subspecialists, e-referrals remain prone to coordination breakdowns. Clear referral policies, well-defined roles and responsibilities for key personnel, standardized procedures and communication protocols, and adequate human resources must be in place before implementing an EHR to facilitate referrals.



Sylvia J Hysong, Donna Espadas, and Hardeep Singh are with the Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houaron, Texas, USA and the Department of Medicine - Health Services Research Section, Baylor College of Medicine, Houston, Texas, USA -- Adol Esquivel is with St. Luke's Episcopal Health System, Houston, Texas, USA -- Dean F. Sittig is with the University of Texas School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, USA -- Lindsey A. Paul is with the School of Social Work, University of Texas at Austin, Austin, Texas, USA -- Simran Singh is with the Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA

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Hysong, Sylvia J., Adol Esquivel, Dean F. Sittig, Lindsey A. Paul, Donna Espadas, Simran Singh, and Hardeep Singh. “Towards Successful Coordination of Electronic Health Record Based-Referrals: A Qualitative Analysis.” Implementation Science 6, no. 1 (July 27, 2011): 84. doi:10.1186/1748-5908-6-84.