Bridging the care continuum: patient information needs for specialist referrals

Patients report high information coordination between rostered primary care physicians and specialists: A cross-sectional study

Our study aimed to describe patient experience of information coordination between their primary care physician and specialists and to examine the associations between their experience and their personal and primary care characteristics. We conducted a cross-sectional study of Ontario residents rostered to a primary care physician and visited a specialist physician in the previous 12 months by linking population-based health administrative data to the Health Care Experience Survey collected between 2013 and 2020. We described respondents' sociodemographic and health care utilization characteristics and their experience of information coordination between their primary care physician and specialists. We measured the adjusted association between patient-reported measures of information coordination before and after respondents received care from a specialist physician and their type of primary care model. 1,460 out 20,422 (weighted 7.5%) of the respondents reported that their specialist physician did not have basic medical information about their visit from their primary care physician in the previous 12 months. 2,298 out of 16,442 (weighted 14.9%) of the respondents reported that their primary care physician seemed uninformed about the care they received from the specialist. Females, younger individuals, those with a college or undergraduate level of education, and users of walk-in clinics had a higher likelihood of reporting a lack of information coordination between the primary care and specialist physicians. Only respondents rostered to an enhanced fee-for-service model had a higher odds of reporting that the specialist physician did not have basic medical information about their visit compared to those rostered to a Family Health Team (OR 1.22, 95% Cl 1.12-1.40). We found no significant association between respondent's type of primary care model and that their primary care physician was uninformed about the care received from the specialist physician. In this population-based health study, respondents reported high information coordination between their primary care physician and specialists. Except for respondents rostered to an enhanced fee-for-service model of care, we did not find any difference in information coordination across other primary care models.

Content validity of patient-reported measures evaluating experiences of the quality of transitions in healthcare settings-a scoping review

No reviews so far have been conducted to define the constructs of patient-experienced quality in healthcare transitions or to identify existing generic measures of patients' experience of the quality within healthcare transitions. Our aim was to identify domains relevant for people experiencing healthcare transitions when evaluating the quality of care they have received, map the comprehensiveness of existing patient-reported experience measures (PREM), and evaluate the PREMs' content validity. The method was guided by the Joanna Briggs Institutes' guidance for scoping reviews. The search was performed on 07 December 2021 and updated 27 May 2024, in the electronic databases Medline (Ovid), Embase (Ovid), and Cinahl (EBSCO). The search identified 20,422 publications, and 190 studies were included for review. We identified 30 PREMs assessing at least one aspect of adults' experience of transitions in healthcare. Summarising the content, we consider a model with two domains, organisational and human-relational, likely to be adequate. However, a more comprehensive analysis and adequate definition of the construct is needed. None of the PREMs were considered content valid.

Interaction at the primary–secondary care interface: Patients’ and physicians’ perceptions of teleconsultations

Introduction

Previous qualitative research on teleconsultations has focused on synchronous communication between a patient and a clinician. This study aims to explore physicians' and patients' perceptions of the interaction on the interface between primary care and the Cardiology service of a referral hospital through teleconsultations.

Methods

This qualitative study was embedded in an organizational case study concerning the introduction and rollout of a new service model that took place at the point of care. The patients and physicians were recruited for semi-structured interviews until thematic saturation was achieved, between September 2019 - January 2020. The interviews were audiorecorded and anonymized. The transcribed interviews were stored, coded, and analyzed in MAXQDA, following the steps for conventional content analysis.

Results

A total of 29 participants were interviewed. Patients and physicians presented clear views about the role of the GP and the cardiologist and their function in overall structure of healthcare. GPs felt their role was to bring expertise in the patient which could supplement the cardiologists' expertise on the condition. However, GPs had to renegotiate roles in the teleconsultations when they saw themselves in a new situation, together with another physician and the patient.

Conclusions

Our findings suggest that joint teleconsultations can promote continuity of care for patients in the primary/secondary care interface. Active coordination between physicians with delineation of roles throughout primary-secondary care interface is needed to manage selected patients who may benefit the most from shared care.

Costs of Specialist Referrals From Employer-Sponsored Integrated Health Care Clinics Are Lower Than Those From Community Providers

BACKGROUND

There have been very few published studies of referral management among commercially insured populations and none on referral management from employer-sponsored health centers.

OBJECTIVE

Describe the referral management system of an integrated employer-sponsored health care system and compare specialist referral rates and costs of specialist visits between those initiated from employer-sponsored health clinics and those initiated from community providers.

DESIGN

Retrospective, comparative cohort study using multivariate analysis of medical claims comparing care initiated in employer-sponsored health clinics with propensity-matched controls having specialist referrals initiated by community providers.

PATIENTS

Adult patients (≥ 18 years) eligible for employer-sponsored clinical services incurring medical claims for specialist referrals between 12/1/2018 and 12/31/2020. The study cohort was comprised of 3129 receiving more than 75% of their care in the employer-sponsored clinic matched to a cohort of 3129 patients receiving care in the community.

INTERVENTION

Specialist referral management program implemented by Crossover Health employer-sponsored clinics.

MAIN MEASURES

Rates and costs of specialist referrals.

KEY RESULTS

The relative rate of specialist referrals was 22% lower among patients receiving care in employers-sponsored health clinics (35.1%) than among patients receiving care in the community (45%, p <0.001). The total per-user per-month cost for patients in the study cohort was $372 (SD $894), compared to $401 (SD $947) for the community cohort, a difference of $29 (p<0.001) and a relative reduction of 7.2%. The lower costs can be attributed, in part, to lower specialist care costs ($63 (SD $140) vs $76 (SD $213) (p<0.001).

CONCLUSIONS

Employer-sponsored health clinics can provide effective integrated care and may be able to reduce avoidable specialist utilization. Standardized referral management and care navigation may drive lower specialist spend, when referrals are needed.

Impact of PTRIA (Patient Test Result Information Act) on patient follow up management

OBJECTIVE

We aim to study if direct patient notification in accordance with the Patient Test Results Information Act (Act 112) in Pennsylvania leads to decreased loss to follow up and prompt management of actionable imaging findings.

METHODS

For this IRB-approved study, radiology reports were randomly identified using the Nuance mPower™ search engine. The actionable finding group (prior to Act-112) contained 300 patients for which a voice notification was sent by radiologists to alert ordering physicians about significant imaging findings. The PTRIA group (after Act-112) contained 300 patients who were mailed a standardized letter one day after the final report was issued. The electronic medical records were reviewed to evaluate how patients were managed.

RESULTS

There was no difference in loss to follow up rates and time to follow up completion between the two groups. In both groups, 34% of patients were lost to follow up in transition of care from generalists to specialists; 24% cases were lost to follow up when imaging findings were not in the area of the initial ordering provider expertise.

CONCLUSION

The goal of Act 112 is to increase patients' role in the timely management of their significant medical conditions and prevent medical errors, specifically loss to follow up. Our study suggests that presumed patients' awareness does not contribute to improved follow up rates or decreased time to a follow up visit. 13% of patients are lost to follow up in both groups. A tracking system is required to prevent delayed management of the significant findings.

Assessing Patient Satisfaction and Experience With an Electronic Referral Process

BACKGROUND AND OBJECTIVES

Our study aimed to identify patients' perception of an eReferral process and e-mail notification system.

METHODS

Patients within the Waterloo Wellington Local Health Integration Network who registered their e-mail address with physicians who adopted the eReferral system, and therefore received e-mail notifications of their booked appointment, were invited to complete an online satisfaction survey. This patient experience survey is an ongoing online link embedded within the confirmation e-mail of the booked appointment. The survey is hosted on the eReferral solution platform and has been operational since November 2017. The survey consists of 8 questions with 3 main categories to assess patients' opinion of their experience of the referral process and notification system using a 5-point Likert scale and open-ended questions.

RESULTS

A total of 545 patients have completed the patient satisfaction survey within this reporting period with a response rate of 15%. In general, 94% of patients agreed that receiving a confirmation e-mail of their booked appointment had improved their experience with the referral process. The majority (94%) agreed that the eReferral process was easy to follow, and 83% agreed that they were able to get the care they needed within a reasonable time. Compared with their past referral experiences, 80% of patients felt more informed throughout this electronic referral process. Using binominal logistic regression, participants whose preferences were considered had 8.06 times higher odds to exhibit satisfaction with the referral process than those who did not. Patients' qualitative responses identified the eReferral process as being quick, efficient, and resulting in a sense of being in control of their own health care. There are some limitations to the system felt by some of the patients who responded to the open-ended questions of the survey. Patients identified the need to add a complementary structure to the notification design consisting of multiple dates and times with a chance to pick the appointment that suits patients best instead of being restricted to only 1 appointment date. A few patients thought that the heading of the e-mail notification system should be more distinguishable for easier tracking. Furthermore, some patients felt the need to add some notes to the initial e-mail advising patients of the next steps throughout their referral process.

CONCLUSION

eReferral has improved patients' experience with the referral process. Our findings in this study would support the solution vendor in its efforts to refine and enhance active communication channels with patients for sustainable health care that meets patients' expectations and needs.

Patients' perception of communication at the interface between primary and secondary care: a cross-sectional survey in 34 countries

BACKGROUND

Poor communication between general practitioners (GPs) and medical specialists can lead to poorer quality, and continuity, of care. Our study aims to assess patients' perceptions of communication at the interface between primary and secondary care in 34 countries. It will analyse, too, whether this communication is associated with the organisation of primary care within a country, and with the characteristics of GPs and their patients.

METHODS

We conducted a cross-sectional survey among patients in 34 countries. Following a GP consultation, patients were asked two questions. Did they take to understand that their GP had informed medical specialists about their illness upon referral? And, secondly, did their GP know the results of the treatment by a medical specialist? We used multi-response logistic multilevel models to investigate the association of factors related to primary care, the GP, and the patient, with the patients' perceptions of communication at the interface between primary and secondary care.

RESULTS

In total, 61,931 patients completed the questionnaire. We found large differences between countries, in both the patients' perceptions of information shared by GPs with medical specialists, and the patients' perceptions of the GPs' awareness of the results of treatment by medical specialists. Patients whose GPs stated that they 'seldom or never' send referral letters, also less frequently perceived that their GP communicated with their medical specialists about their illness. Patients with GPs indicating they 'seldom or never' receive feedback from medical specialists, indicated less frequently that their GP would know the results of treatment by a medical specialist. Moreover, patients with a personal doctor perceived higher rates of communication in both directions at the interface between primary and secondary care.

CONCLUSION

Generally, patients perceive there to be high rates of communication at the interface between primary and secondary care, but there are large differences between countries. Policies aimed at stimulating personal doctor arrangements could, potentially, enhance the continuity of care between primary and secondary care.

Closing the loop with an enhanced referral management system

Objective

To evaluate the impact of a referral manager tool on primary care practices.

Materials and Methods

We evaluated a referral manager module in a locally developed electronic health record (EHR) that was enhanced to improve the referral management process in primary care practices. Baseline (n = 61) and follow-up (n = 35) provider and staff surveys focused on the ease of performing various steps in the referral process, confidence in completing those steps, and user satisfaction. Additional metrics were calculated that focused on completed specialist visits, acknowledged notes, and patient communication.

Results

Of 1341 referrals that were initiated during the course of the study, 76.8% were completed. All the steps of the referral process were easier to accomplish following implementation of the enhanced referral manager module in the EHR. Specifically, tracking the status of an in-network referral became much easier (+1.43 [3.91-2.48] on a 5-point scale, P < .0001). Although we found improvement in the ease of performing out-of-network referrals, there was a greater impact on in-network referrals.

Discussion

Implementation of an electronic tool developed using user-centered design principles along with adequate staff to monitor and intervene when necessary made it easier for primary care practices to track referrals and to identify if a breakdown in the process occurred. This is especially important for high-priority referrals. Out-of-network referrals continue to present challenges, which may eventually be helped by improving interoperability among EHRs and scheduling systems.

Conclusion

An enhanced referral manager system can improve referral workflows, leading to enhanced efficiency and patient safety and reduced malpractice risk.

Improving the Referral Process, Timeliness, Effectiveness, and Equity of Access to Specialist Medical Services Through Electronic Consultation: Pilot Study

BACKGROUND

Access to specialty care remains a major challenge in the Canadian health care system. Electronic consultation (eConsult) services allow primary care providers to seek specialist advice often without needing the patient to go for a face-to-face consultation. It improves overall access to specialists and the referral process using an electronic care consultation service in urban and rural primary care clinics. This study describes the preliminary results of a pilot study with an eConsult service across 3 regions in the province of Quebec, Canada.

OBJECTIVE

The main objective of this study was to provide a 1-year snapshot of the implementation of the eConsult Quebec Service in rural and urban primary care clinics to improve access to care and the specialty referral process for primary care providers (PCPs).

METHODS

We established an eConsult service that covers urban and rural communities in 3 regions of Quebec. We conducted a quantitative analysis of all eConsult cases submitted from July 4, 2017, to December 8, 2018.

RESULTS

For over a year, 1016 eConsults have been generated during the course of this study. A total of 97 PCPs submitted requests to 22 specialty groups and were answered by 40 different specialists. The most popular specialty was internal medicine (224/1016, 22%). Overall, 63% (640/1016) of completed cases did not require a face-to-face visit. PCPs rated the service as being of high or very high value for themselves in 98% (996/1016) of cases.

CONCLUSIONS

The preliminary data highlight the success of the implementation of the eConsult Quebec Service across 6 primary care clinics. The eConsult platform proves to be effective, efficient, and well received by both patients and physicians. If used more widely, eConsult could help reducing wait times significantly. Recently, the Ministry of Health and Social Services of Quebec has identified developing a strategic plan to scale eConsults throughout other regions of the province as a top priority.

The role of hospitals in bridging the care continuum: a systematic review of coordination of care and follow-up for adults with chronic conditions

Background

Multiple studies have investigated the outcome of integrated care programs for chronically ill patients. However, few studies have addressed the specific role hospitals can play in the downstream collaboration for chronic disease management. Our objective here is to provide a comprehensive overview of the role of the hospitals by synthesizing the advantages and disadvantages of hospital interference in the chronic discourse for chronically ill patients found in published empirical studies.

Method

Systematic literature review. Two reviewers independently investigated relevant studies using a standardized search strategy.

Results

Thirty-two articles were included in the systematic review. Overall, the quality of the included studies is high. Four important themes were identified: the impact of transitional care interventions initiated from the hospital’s side, the role of specialized care settings, the comparison of inpatient and outpatient care, and the effect of chronic care coordination on the experience of patients.

Conclusion

Our results show that hospitals can play an important role in transitional care interventions and the coordination of chronic care with better outcomes for the patients by taking a leading role in integrated care programs. Above that, the patient experiences are positively influenced by the coordinating role of a specialist. Specialized care settings, as components of the hospital, facilitate the coordination of the care processes. In the future, specialized care centers and primary care could play a more extensive role in care for chronic patients by collaborating.

ASSESSING REFERRALS AND IMPROVING INFORMATION AVAILABILITY FOR CONSULTATIONS IN AN ACADEMIC ENDOCRINOLOGY CLINIC

OBJECTIVE

Outpatient specialty consultations rely on the timeliness and completeness of referral information to facilitate a valuable patient-specialist interaction. This project aimed to increase essential diagnostic information availability at the initial consultation for patients referred for common endocrine conditions frequently lacking such data-diabetes mellitus, thyroid nodule, thyrotoxicosis, and hypercalcemia.

METHODS

At an endocrinology clinic at an academic medical center in rural New England, providers see several thousand new patients annually, the majority of whom are referred by providers external to the clinic's healthcare system. Through consensus, endocrinology clinic providers agreed on the two or three data elements essential for a meaningful initial consultation for each. A quality improvement team employed a planned series of interventions based on previously published methods and an innovative approach: dissemination of a referral guideline, an assessment of referral adequacy in the endocrinology clinic workflow, coupled with focused requests for missing items, and a pre-visit lab appointment.

RESULTS

Between April 2015 and March 2016, 762 referrals were reviewed. At baseline for the four conditions, referrals contained all essential elements only 27.5% (22 of 80) of the time. Over a 7-month period, the team implemented the interventions, with subsequent referrals containing all essential elements increasing to 75.5% (P<.0001), largely attributable to the pre-visit lab appointment.

CONCLUSION

Incoming referrals that lack essential information are a significant problem in specialty care and may adversely affect patient experience, provider satisfaction, and clinic efficiency. Improvement may require innovative approaches, such as the potentially transferable and generalizable ones employed here.

ABBREVIATIONS

DHMC = Dartmouth-Hitchcock Medical Center EHR = electronic health record PDSA = Plan-Do-Study-Act.

Providing specialty consultant expertise to primary care: an expanding spectrum of modalities

In most models of health care delivery, the bulk of services are provided in primary care and there is frequent request for the input of specialty consultants. A critical issue for current and future health care systems is the effective and efficient delivery of specialist expertise for clinicians and patients. Input on a patient's care from specialty consultants usually requires a face-to-face visit between the patient and the consultant. New and complementary models of knowledge sharing have emerged. We describe a framework assessment of a spectrum of knowledge-sharing methods in the context of a patient-centered medical home. This framework is based on our experience in the Veterans Health Administration and a purposive review of the literature. These newer modes of specialty consultation include electronic consultation, secure text messaging, telemedicine of various types, and population preemptive consults. In addition to describing these modes of consultation, our framework points to several important areas in which further research is needed to optimize effectiveness.

Factors associated to experienced continuity of care between primary and outpatient secondary care in the Catalan public healthcare system

OBJECTIVE

To analyze patient's reported elements of relational, informational and managerial (dis)continuity between primary and outpatient secondary care and to identify associated factors.

METHODS

Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care for the same condition. The study settings consisted of three health areas of the Catalan health system. Data were collected in 2010 using the CCAENA questionnaire, which identifies patients' experiences of continuity of care. Descriptive analyses and multivariable logistic regression models were carried out.

RESULTS

Elements of continuity of care were experienced by most patients. However, elements of discontinuity were also identified: 20% and 15% were seen by more than one primary or secondary care physician, respectively. Their secondary care physician or both professionals were identified as responsible for their care by 40% and 45% of users, respectively. Approximately 20% reported a lack of information transfer. Finally, 72% of secondary care consultations were due to primary care referral, whilst only 36% reported a referral back to primary care. Associated factors were healthcare setting, age, sex, perceived health status and disease duration.

CONCLUSION

Users generally reported continuity of care, although elements of discontinuity were also identified, which can be partially explained by the healthcare setting and some individual factors. Elements of discontinuity should be addressed to better adapt care to patients' needs.

A qualitative examination of health and health care utilization after the September 11th terror attacks among World Trade Center Health Registry enrollees

Background

Many individuals who have 9/11-related physical and mental health symptoms do not use or are unaware of 9/11-related health care services despite extensive education and outreach efforts by the World Trade Center (WTC) Health Registry (the Registry) and various other organizations. This study sought to evaluate Registry enrollees’ perceptions of the relationship between physical and mental health outcomes and 9/11, as well as utilization of and barriers to 9/11-related health care services.

Methods

Six focus groups were conducted in January 2010 with diverse subgroups of enrollees, who were likely eligible for 9/11-related treatment services. The 48 participants were of differing race/ethnicities, ages, and boroughs of residence. Qualitative analysis of focus group transcripts was conducted using open coding and the identification of recurring themes.

Results

Participants described a variety of physical and mental symptoms and conditions, yet their knowledge and utilization of 9/11 health care services were low. Participants highlighted numerous barriers to accessing 9/11 services, including programmatic barriers (lack of program visibility and accessibility), personal barriers such as stigmatization and unfamiliarity with 9/11-related health problems and services, and a lack of referrals from their primary care providers. Moreover, many participants were reluctant to connect their symptoms to the events of 9/11 due to lack of knowledge, the amount of time that had elapsed since 9/11, and the attribution of current health symptoms to the aging process.

Conclusions

Knowledge of the barriers to 9/11-related health care has led to improvements in the Registry’s ability to refer eligible enrollees to appropriate treatment programs. These findings highlight areas for consideration in the implementation of the new federal WTC Health Program, now funded under the James Zadroga 9/11 Health and Compensation Act (PL 111-347), which includes provisions for outreach and education.

Crossing the chasm: information technology to biomedical informatics

Accelerating the translation of new scientific discoveries to improve human health and disease management is the overall goal of a series of initiatives integrated in the National Institutes of Health (NIH) "Roadmap for Medical Research." The Clinical and Translational Science Award (CTSA) program is, arguably, the most visible component of the NIH Roadmap providing resources to institutions to transform their clinical and translational research enterprises along the goals of the Roadmap. The CTSA program emphasizes biomedical informatics as a critical component for the accomplishment of the NIH's translational objectives. To be optimally effective, emerging biomedical informatics programs must link with the information technology platforms of the enterprise clinical operations within academic health centers.This report details one academic health center's transdisciplinary initiative to create an integrated academic discipline of biomedical informatics through the development of its infrastructure for clinical and translational science infrastructure and response to the CTSA mechanism. This approach required a detailed informatics strategy to accomplish these goals. This transdisciplinary initiative was the impetus for creation of a specialized biomedical informatics core, the Center for Biomedical Informatics (CBI). Development of the CBI codified the need to incorporate medical informatics including quality and safety informatics and enterprise clinical information systems within the CBI. This article describes the steps taken to develop the biomedical informatics infrastructure, its integration with clinical systems at one academic health center, successes achieved, and barriers encountered during these efforts.

A coordenação da assistência no controle da tuberculose

Estudo epidemiológico descritivo que analisa a coordenação da assistência ao doente de Tuberculose em Serviços de Atenção Primária segundo 23 doentes, 16 profissionais e 17 gestores em Ribeirão Preto-SP, através de instrumento adaptado para avaliar a tuberculose. De acordo com os informantes, a coordenação da assistência ao doente em tratamento pela equipe do programa de controle da tuberculose foi considerada satisfatória. No entanto, quando há necessidade de encaminhar o doente a outros pontos de atenção, a coordenação da assistência apresenta pontos deficientes como descontinuidade do fluxo de comunicação e participação incipiente do doente no processo de atenção, havendo necessidade de aumentar a responsabilização pelo cuidado do doente e estimulá-lo como agente ativo do processo.

Quality of life information and trust in physicians among families of children with life-limiting conditions

Purpose:

To examine information that parents of children with life-limiting conditions want to discuss with children’s physicians to assist decision-making, and whether the desire for this information is associated with parents’ trust in physicians.

Study design:

A cross-sectional study using a telephone survey.

Patients and methods:

Subjects comprised a random sample of 266 parents whose children were enrolled in Florida’s Medicaid Program. Parents were asked if they wanted to discuss information related to their children’s treatment, including quality of life (QOL), pain relief, spiritual beliefs, clinical diagnosis/laboratory data, changes in the child’s behavior due to treatment, changes in the child’s appearance due to treatment, chances of recovery, and advice from the physician and family/friends. The Wake Forest Physician Trust Scale was used to measure parents’ trust in physicians. We tested the relationships between parents’ age, race/ethnicity, education, parent-reported children’s health status, and the desired information. We also tested whether the desire for information was associated with greater trust in physicians.

Results:

Most parents wanted information on their children’s QOL (95%), followed by chance of recovery (88%), and pain relief (84%). Compared with nonHispanic whites, nonHispanic blacks and Hispanics showed a greater desire for information and a chance to discuss QOL information had greater trust in their children’s physicians than other information after adjusting for covariates (P < 0.05).

Conclusions:

Among children with life-limiting conditions, QOL is the most frequently desired information that parents would like to receive from physicians as part of shared decision-making. Parents’ desire for QOL information is associated with greater trust in their children’s physicians.