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Challenges in Referral Communication between VHA Primary Care and Specialty Care

Zuchowski J, Rose DE, Stockdale S, Hamilton A, Meredith LS, Yano EM, Rubenstein LV, Cordasco KM. Challenges in Referral Communication between VHA Primary Care and Specialty Care. Paper presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.

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Research Objective: A growing body of literature suggests that primary-specialty communication is a significant problem within the U.S. health care system and a detriment to effective care coordination. Integrated delivery systems and the use of a shared electronic medical record (EMR) have been shown to facilitate primary-specialty communication. Little is known about persistent sources of variation in referral communication between primary care and specialty care in environments that already benefit from an integrated delivery system and an EMR, such as the Veteran Health Administration (VHA). We explored the prevalence and nature of communication challenges faced by VHA primary care providers (PCPs) and specialty providers, with a particular focus on referrals. Study Design: Using mixed methods, we conducted an online survey which assessed PCP-reported ease of communication with specialists, and semi-structured qualitative interviews with PCPs, primary care staff, clinical and regional leaders, and other primary care key stakeholders. We asked PCPs, "How easy it is for you to communicate [in person, by phone, or electronically] with the following types of health services providers?" Response options ranged on a 3-point Likert scale from "very easy" to "somewhat easy" or "not at all easy." We analyzed interview transcripts using keyword search and autocoding in Atlas.ti (version 6), and identified recurrent themes relevant to PCP-specialist referral communication. Population studied: We surveyed VHA PCPs from one regional network, and we interviewed VHA PCPs, primary care staff, clinical and regional leaders, and other primary care key stakeholders from three health systems within the same network. Principal Findings: Among 191 survey respondents (54% response rate), specialties rated with highest percentage "very easy" and "somewhat easy" communication were: pharmacy (98%), social work (93%), and women's health (80%). Specialties rated with the lowest percentage of "very easy" and "somewhat easy" communication were: cardiothoracic surgery (29%), neurology (51%), and general surgery (58%). Among the 97 interviewees (66% response rate, with 43% of interviews containing relevant content,) communication challenges most frequently expressed were: 1) difficulty communicating special requests for appointments within a certain timeframe using the EMR platform, and 2) frequent rejection of referral requests. When faced with these referral communication challenges, PCPs reported using EMR "work around" strategies, such as telephone and email contact with specialists based in personal relationships. Conclusions: Primary-specialty communication is a persistent problem that varies by specialty. Despite the supporting factors of an integrated system and a shared EMR, referral communication is still frequently viewed as difficult. Personal relationships between PCPs and specialists may play a role in facilitating referral communication outside the EMR. Implications for Policy and Practice: EMRs should be designed to facilitate bi-directional communication between PCPs and specialists in order to improve effective triaging of time-sensitive referrals and avoid referral rejections. Efforts to improve PCPs' and specialists' familiarity with, and trust in, each other may improve referral communication when providers face EMR-related referral communication challenges. More study is required to determine EMR-based mechanisms for bi-directional communication and practice structures that build relationships between PCPs and specialty providers.

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