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