2019 HSR&D/QUERI National Conference

1062 — Cognitive requirements for referring primary care providers: Supporting goals, tasks, and decisions

Lead/Presenter: April Savoy,  COIN - Indianapolis
All Authors: Savoy April (Center for Health Information and Communication, Richard L. Roudebush VA Medical Center), Militello L (Applied Decision Science, LLC, Cincinnati, Ohio), Diiulio J (Applied Decision Science, LLC, Cincinnati, Ohio) Midboe AM (Center for Innovation to Implementation, VA Palo Alto Health Care System, Stanford University, Palo Alto, CA) Weiner M (Center for Health Information and Communication Richard L. Roudebush VA Medical Center, Indianapolis, Indiana) Abbasadegan H (Phoenix VA Health Care System, Phoenix, AZ) Herout J (Human Factors Engineering, Health Informatics, Office of Health Informatics and Analytics, Veterans Health Administration, Washington, DC)

Although referrals for specialty consultations are a core clinical process, social and technical aspects of the process make referrals prone to coordination and communication breakdowns. These breakdowns increase delays in diagnosis and treatment, as well as physician workload and risks to patient safety. This study sought to identify and describe the cognitive requirements and associated information needs of referring primary care providers (PCPs) during the referral process as well as characterize referring PCPs' experiences with current health information technology.

We interviewed 62 referring PCPs. We recruited convenience samples of participants, who were stratified across three VA medical centers, geographically dispersed across the U.S. Our four-member analysis team used hierarchical task analysis to construct a goal-directed hierarchy. Also, we utilized extensions of the task analysis to describe PCPs' common experiences with health information technologies throughout the referral process.

The resultant goal hierarchy includes one main goal (Referral for Additional Care), two sub-goals (Assess Patient's Condition and Manage Referrals), and four major tasks with respective decisions (What type of specialist is warranted; What information should I provide; What additional action is needed; and How to integrate specialists' findings). Approximately 22 information needs were commonly identified and PCPs described their use of various sources - other PCPs, electronic health records, chat software, and paper- to satisfy those information needs.

Cognitive demand for referring PCPs is high throughout the referral process. They have to search, identify, compose, track, and integrate information across multiple screens, systems, and people. Existing interfaces do not adequately support the communication, information exchange, or care coordination related to the referral process. Prioritizing identification of information needs and how information is displayed would address current issues related to information overload, information scatter, and missing information.

Results from this study provide an important foundation for developing patient-centered displays that support PCPs' decision-making process and reduce cognitive challenges. With these results, information requirements can be developed to guide the development of user interfaces that better support the referral process and its related communication, information exchange, and care coordination.