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2023 HSR&D/QUERI National Conference Abstract

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4069 — Cerner Millennium’s Care Pathways for Specialty Care Referrals: Provider and Nurse Perceptions and Recommendations for Improvements

Lead/Presenter: Kristina Cordasco,  COIN - Los Angeles
All Authors: Cordasco KM (Center for the Study of Healthcare Innovations, Implementation & Policy), Gable AR (Center for the Study of Healthcare Innovations, Implementation & Policy); Ganz DA (Center for the Study of Healthcare Innovations, Implementation & Policy); Smith A (Center for the Study of Healthcare Innovations, Implementation & Policy); Brunner JW (Center for the Study of Healthcare Innovations, Implementation & Policy); Fix GM (Center for the Study of Healthcare Innovations, Implementation & Policy)

Objectives:
Electronic health record (EHR) tools are integral to supporting communication across providers, particularly for specialty referrals. The Veterans Health Administration (VA) is transitioning its EHR to Cerner Millennium, with initial deployment in October 2020 at the Mann-Grandstaff VA. Cerner Millennium features custom-made “Care Pathways” -- templated electronic forms with clinical decision support (CDS) prompting any missing pre-referral testing orders -- to guide referring providers and capture information needed for referral triage and care. We elicited Mann-Grandstaff providers’ and nurses’ perceptions and recommendations for improvements in Care Pathways.

Methods:
Guided by the socio-technical model, we conducted interviews with 15 primary care providers (PCPs), 11 nurses who support PCPs by “proposing” referrals for PCP signature, and 4 specialist providers who both send referrals (to other specialists) and receive them at the Mann-Grandstaff VA. Qualitative interviews were conducted November 2021-February 2022 (providers) and June-July 2022 (nurses). Interviews were recorded, transcribed, summarized, and analyzed using constant comparison.

Results:
Most nurses, and a few PCPs, liked the Care Pathways premise and logic, describing the CDS prompts for pre-referral testing as useful, especially in the context of long waits for specialty care in their community. However, since they had usually already ordered needed tests, especially for referrals made frequently, most PCPs and all specialists found the CDS framework to be redundant and impede workflow. Almost all providers, and some nurses, strongly recommended that Care Pathways be revised to decrease the time it takes to navigate through them by improving their layout and efficiency and, concordantly, decreasing the number of clicks required. Interviewees reported that too many pathway options, non-intuitive organization, unfamiliar nomenclature, and a rudimentary search function made it difficult for them to find the appropriate pathway. Required information was viewed as sometimes redundant, not applicable to the situation, and/or administrative (non-clinical). Providers and nurses described often not knowing the details required by the pathways (e.g., date of last mammogram), resulting in them exiting the pathway, looking up information and starting again. As such, employing additional data autofill and enabling users to toggle between pathways and chart information were common top recommendations. Specialists reported not receiving the Care Pathway data entered by referring providers, instead engaging in manual record review to retrieve information needed for referral triage and completion; specialists cited receiving unclear and incomplete information in referral orders as a patient safety concern and addressing this issue was a top recommendation.

Implications:
Mann-Grandstaff VA providers and nurses recommended enhancements to Cerner Millennium’s “Care Pathways” to improve workflow efficiencies while transmitting information needed to facilitate referral triage and care. There were notable differences in perceptions between nurses and providers.

Impacts:
As VA continues to work towards optimizing Cerner Millennium’s Care Pathways, information entry by the referring provider should be streamlined, employing automation and further use of user-centered design principles. Furthermore, pathway information entered by the referring provider needs to be made accessible to specialists. Frontline staff perceptions and recommendations in later implementation sites, which may benefit from ongoing improvements in system enhancements and training, should be assessed.