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Cognitive Challenges, Technological Factors, and Communication of Medical Referrals and Consultations

Weiner M, Barker B, Midboe A, Porter B, Adams J, Wu J, Flanagan ME, Savoy A, Rehman S, Abbaszadegan H, Russ AL, Thurmond C, Haggstrom DA, Frankel RM, Militello L. Cognitive Challenges, Technological Factors, and Communication of Medical Referrals and Consultations. Paper presented at: Human Factors and Ergonomics Society Annual Symposium on Human Factors and Ergonomics in Health Care; 2016 Apr 13; San Diego, CA.


Objectives: Barriers to consultation lead to delays in medical care and adverse events for patients. About a third of patients are referred to subspecialty consultants for evaluation or management of disease. The referral process is varied and complex: about a third of Veterans Affairs (VA) referrals are cancelled, and about half of the cancelled referrals are not pursued further within 30 days. Electronic health record (EHR) systems typically include referral modules with menus to select a consultant, and templates to provide clinical details, but these modules often present challenges of their own. Our objectives were to identify barriers, facilitators, and suggested improvements to the referral process, with attention to human-computer interaction; and characterize teamwork and communication between referrers and consultants. Methods: We interviewed and observed primary care and subspecialty clinic staff members involved in referral and consultation processes at two VA medical centers. We used semi-structured interviews in which participants were asked to describe referrals that had gone smoothly and referrals that had been particularly problematic. They were asked about their methods for tracking referrals, communication between primary careand specialty clinics, coordination of care, and approaches to follow-up. Interviews also included questions about how the EHR system is used during the referral process, with a focus on the efficiencies, shortcomings, and potential improvements of referral template forms. We observed clinical encounters to obtain information about how consultations occur in the context of clinical workflow and to observe referrers and consultants interacting with the EHR system. Data from interviews and observations were coded from transcripts and observation logs and used to identify and describe emergent, salient themes in an inductive qualitative analysis. Themes were then discussed and prioritized to inform the design of clinical decision support features. Results: We conducted 42 interviews and 37 observations with healthcare professionals. We identified the key steps in the process of referral and consultation: referral request, triage of referrals (e.g., decision about whether the referral should be cancelled or scheduled), scheduling of patient, consultation, and follow-up by referrer. Three primary cognitive challenges emerged: the decision to request a consultation; triage; and tracking. Many barriers associated with the cognitive challenges were noted. For example, lengthy, confusing EHR referral menus were associated with selection of inappropriate consulting services; lengthy, confusing, and unstandardized templates led to insufficient information for triage; differences of opinion about pre-consultation requirements occurred between referrer and consultant; appropriate points of contact for questions or discussion were often unknown; and tracking and follow-up communication, such as in the case of missing information or a cancellation, were often absent. Electronic messages about referrals contained inadequate information to convey their importance, what action was needed, or why. Implications for Design: The three cognitive challenges will drive recommendations for improvement. For example, addressing the first cognitive challenge, the decision to request a consultation, will include strategies to help referrers anticipate what the consultant needs to know. The second cognitive challenge, the triage process of screening referrals for appropriateness, is tightly linked to the first. By aiding primary referrers in submitting specific and relevant information with the referral, specialty clinics will have the information that they need to triage referrals effectively. Addressing the third cognitive challenge, tracking consultations, includes providing better tools to help referrers. This will aid providers in determining whether and when further action is required following referral. Conclusion: The current VA referral and consultation process was found to have many barriers. The EHR system helps some aspects of referral and consultation but hinders others. The referral request, triage, and tracking of referrals represent key areas of challenge. Improved templates, tracking tools, and opportunities for real-time communication between referrers and consultants may improve efficiency, satisfaction, and timeliness of care.

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