Health Services Research & Development

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Research Highlight

As VHA moves to a team-based model of care, care coordination becomes ever more important. Coordinating care is not a new task in the delivery system, by any means. Yet, despite the many recommendations of entities like the Institute of Medicine that emphasize the importance of well-coordinated health care, guidance on how to coordinate it in order to achieve best results is scarce. One of the most common and longstanding forms of coordination is referring a patient to a subspecialist. Referrals serve as an excellent laboratory for understanding how to best coordinate amongst health care providers.

Researchers have long lauded the electronic health record (EHR) as an important tool with significant potential to improve care coordination in the context of referrals. EHRs allow the primary care provider (PCP) and subspecialist to exchange information instantaneously, and provide both with immediate access to the entire patient record. However, around 7 percent of patients referred to subspecialists are still lost to follow up despite providers who use an EHR in the referral process. This observation suggests we may need to understand how to optimize information communication through an EHR.

We conducted a qualitative study at two large tertiary care VA Medical Centers (VAMC) from different geographical areas in order to: (1) understand coordination breakdowns related to e-referrals; and (2) examine work-system factors that affect the timely receipt of subspecialty care. 1, 2 First, we conducted interviews with seven subject matter experts to document and understand the e-referral process workflow at four high-volume referral subspecialty clinics at one VAMC. We created subspecialty-specific referral process maps capturing workflow, information transfer, and actions needed for processing referrals. We found considerable variability across subspecialties in how they handled an incoming referral request; nevertheless, seven summary steps emerged as necessary to successfully coordinate transition to a subspecialist: (1) PCP places the referral request; (2) subspecialist reviews the request; (3) subspecialist communicates the review decision; (4) responsibility for care is transferred from primary to specialty care; (5) the referral encounter occurs; (6) the care plan is communicated to the PCP; and (7) responsibility for care is transferred back to primary care.

Next, we conducted six focus groups with a total of 30 PCPs from both VAMCs. Using techniques from grounded theory and content analysis, we identified four organizational themes that affected the referral process: (1) lack of an institutional referral policy; (2) lack of standardization in certain referral procedures; (3) ambiguity in roles and responsibilities; and (4) 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 that would facilitate coordination and successful referral completion. Notably, providers reported very few barriers related to the EHR itself.

Our study began as an examination of specific aspects of EHRs that formed barriers to coordination through referrals, hopefully to serve as pathways for improving the EHR. Our most important finding was that the key to successful care coordination depends less on the EHR interface, and far more on the basics of coordination itself: a clear, institutional referral policy and standardized referral practices that everyone was aware of and understood; a clear understanding by all concerned about which provider is responsible for which aspect of care; and adequate resources (personnel or otherwise) to adapt and respond to incoming referral requests. In their evidence-based coordination framework, Okhuysen and Bechky suggest three integrating conditions that must be present for coordination to occur successfully: accountability (clarity over who is responsible for what), predictability (knowing what tasks are involved and when they happen), and common understanding (a shared perspective on the whole process being coordinated and how individuals' work fits within the whole). 3 As we found in our study, the EHR can help improve accountability (for example, by restricting permission for certain actions exclusively to those who are responsible for completing them) and, to some extent, common understanding (for example, by displaying all clinicians currently providing care for a given patient and their role in the care team for that patient), but is quite limited in its ability to improve predictability as defined above. Even in areas where EHRs can help, there are still basic decisions about coordinating that must be done by humans. Deciding who is responsible for information gathering and patient workup, for example, is something that must be done by people. In short, the EHR is only as good as the policies, procedures, and human decisions that it is designed to support.

  1. Hysong, S.J. et al. "Improving Outpatient Safety through Effective Electronic Communication: A Study Protocol," Implementation Science 2009; 4(62).
  2. Hysong, S.J. et al. "Toward Successful Coordination of Electronic Health Record Based-Referrals: A Qualitative Analysis," Implementation Science 2011; 6(84).
  3. Okhuysen, G.A. and B.A. Bechky. "Coordination in Organizations: An Integrative Perspective," Academy of Management Annals , 2009 Jun; 3(1):463-502.