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Batool S, Hansen EE, Sethi RKV, Rettig EM, Goguen LA, Annino DJ, Uppaluri R, Edwards HA, Faden DL, Schnipper JL, Dohan D, Reich AJ, Bergmark RW. Perspectives on Referral Pathways for Timely Head and Neck Cancer Care. JAMA Otolaryngol Head Neck Surg 2024; 150:545-554. [PMID: 38753343 PMCID: PMC11099838 DOI: 10.1001/jamaoto.2024.0917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/22/2024] [Indexed: 05/19/2024]
Abstract
Importance Timely diagnosis and treatment are of paramount importance for patients with head and neck cancer (HNC) because delays are associated with reduced survival rates and increased recurrence risk. Prompt referral to HNC specialists is crucial for the timeliness of care, yet the factors that affect the referral and triage pathway remain relatively unexplored. Therefore, to identify barriers and facilitators of timely care, it is important to understand the complex journey that patients undertake from the onset of HNC symptoms to referral for diagnosis and treatment. Objective To investigate the referral and triage process for patients with HNC and identify barriers to and facilitators of care from the perspectives of patients and health care workers. Design, Participants, and Setting This was a qualitative study using semistructured interviews of patients with HNC and health care workers who care for them. Participants were recruited from June 2022 to July 2023 from HNC clinics at 2 tertiary care academic medical centers in Boston, Massachusetts. Data were analyzed from July 2022 to December 2023. Main Outcomes and Measures Themes identified from the perspectives of both patients and health care workers on factors that hinder or facilitate the HNC referral and triage process. Results In total, 72 participants were interviewed including 42 patients with HNC (median [range] age, 60.5 [19.0-81.0] years; 27 [64%] females) and 30 health care workers (median [range] age, 38.5 [20.0-68.0] years; 23 [77%] females). Using thematic analysis, 4 major themes were identified: the HNC referral and triage pathway is fragmented; primary and dental care are critical for timely referrals; efficient interclinician coordination expedites care; and consistent patient-practitioner engagement alleviates patient fear. Conclusions and Relevance These findings describe the complex HNC referral and triage pathway, emphasizing the critical role of initial symptom recognition, primary and dental care, patient information flow, and interclinician and patient-practitioner communication, all of which facilitate prompt HNC referrals.
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Affiliation(s)
- Sana Batool
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Elisabeth E. Hansen
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School and Massachusetts Eye and Ear, Boston
| | - Rosh K. V. Sethi
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Eleni M. Rettig
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Laura A. Goguen
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Donald J. Annino
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ravindra Uppaluri
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Heather A. Edwards
- Department of Otolaryngology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Daniel L. Faden
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School and Massachusetts Eye and Ear, Boston
- Department of Otolaryngology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Hospital Medicine Unit and Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Daniel Dohan
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Amanda J. Reich
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Regan W. Bergmark
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School and Massachusetts Eye and Ear, Boston
- Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Aljerian NA, Alharbi AA, Alghamdi HA, Binhotan MS, AlOmar RS, Alsultan AK, Arafat MS, Aldhabib A, Alabdulaali MK. External Vs Internal e-Referrals: Results from a Nationwide Epidemiological Study Utilizing Secondary Collected Data. Risk Manag Healthc Policy 2024; 17:739-751. [PMID: 38562249 PMCID: PMC10984205 DOI: 10.2147/rmhp.s453042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/23/2024] [Indexed: 04/04/2024] Open
Abstract
Background E-referral systems, streamlining patient access to specialists, have gained global recognition yet lacked a comparative study between internal and external referrals in Saudi Arabia (KSA). Methods This retrospective study utilized secondary data from the Saudi Medical Appointments and Referrals Centre system. The data covers 2020 and 2021, including socio-demographic data, referral characteristics, and specialties. Logistic regression analysis was used to assess factors associated with external referrals. Results Out of 645,425 e-referrals from more than 300 hospitals, 19.87% were external. The northern region led with 48.65%. Males were 55%, and those aged 25-64 were 56.68% of referrals. Outpatient clinic referrals comprised 47%, while 61% of referrals were due to a lack of specialty services. Several significant determinants are associated with higher rates of external referral with (p-value <0.001) and a 95% Confidence interval. Younger individuals under 25 exhibit higher referral rates than those aged 25-64. Geographically, compared to the central region, in descending order, there were increasing trends of external referral in the northern, western, and southern regions, respectively (OR = 19.26, OR = 4.48, OR 3.63). External referrals for outpatient departments (OPD) and dialysis services were higher than for routine admissions (OR = 1.38, OR = 1.26). The rate of external referrals due to the lack of available equipment was more predominant than other causes. Furthermore, in descending order, external referrals for organ transplantation and oncology are more frequent than for medical specialties, respectively (OR = 9.39, OR = 4.50). Conclusion The study reveals trends in e-referrals within the KSA, noting regional differences, demographic factors, and types of specialties regarding external referrals, benefiting the New Model of Care for the 2030 Vision. Findings suggest expanding virtual consultations to reduce external referrals. Strengthening primary care and preventive medicine could also decrease future referrals. Future studies should assess resource distribution, including infrastructure and workforce, to further inform healthcare strategy.
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Affiliation(s)
- Nawfal A Aljerian
- Medical Referrals Centre, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
- Emergency Medicine Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah A Alharbi
- Family and Community Medicine Department, Jazan University, Jazan, Kingdom of Saudi Arabia
| | - Hani A Alghamdi
- Department of Family and Community Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Meshary S Binhotan
- Emergency Medical Services Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Reem S AlOmar
- Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Ali K Alsultan
- Medical Referrals Centre, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed S Arafat
- Medical Referrals Centre, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
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Aljerian N, Alharbi A. Assessing Medical Emergency E-referral Request Acceptance Patterns and Trends: A Comprehensive Analysis of Secondary Data From the Kingdom of Saudi Arabia. Cureus 2024; 16:e53511. [PMID: 38314384 PMCID: PMC10838169 DOI: 10.7759/cureus.53511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.
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Affiliation(s)
- Nawfal Aljerian
- Emergency Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Emergency Medicine, Medical Referrals Centre, Ministry of Health, Riyadh, SAU
| | - Abdullah Alharbi
- Family and Community Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
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Campaz-Landazábal D, Vargas I, Vázquez ML. Impact of coordination mechanisms based on information and communication technologies on cross-level clinical coordination: A scoping review. Digit Health 2024; 10:20552076241271854. [PMID: 39130524 PMCID: PMC11311193 DOI: 10.1177/20552076241271854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 07/04/2024] [Indexed: 08/13/2024] Open
Abstract
Background Coordination mechanisms based on information and communication technologies (ICTs) are gaining attention, especially since the pandemic, due to their potential to improve communication between health professionals. However, their impact on cross-level clinical coordination remains unclear. The aim is to synthesize the evidence on the impact of ICT-based coordination mechanisms on clinical coordination between primary care and secondary care (SC) doctors and to identify knowledge gaps. Methods A scoping review was conducted by searching for original articles in six electronic databases and a manual search, with no restrictions regarding time, area, or methodology. Titles and abstracts were screened. Full texts of the selected articles were reviewed and analysed to assess the impact of each mechanism, according to the cross-level clinical coordination conceptual framework. Results Of the 6555 articles identified, 30 met the inclusion criteria. All had been conducted in high-income countries, most (n = 26) evaluated the impact of a single mechanism - asynchronous electronic consultations via electronic health records (EHR) - and were limited in terms of design and types and dimensions of cross-level clinical coordination analysed. The evaluation of electronic consultations showed positive impacts on the appropriateness of referrals and accessibility to SC, yet the qualitative studies also highlighted potential risks. Studies on other mechanisms were scarce (shared EHR, email consultations) or non-existent (videoconferencing, mobile applications). Conclusions Evidence of the impact of ICT-based mechanisms on clinical coordination between levels is limited. Rigorous evaluations are needed to inform policies and strategies for improving coordination between healthcare levels, thus contributing to high-quality, efficient healthcare.
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Affiliation(s)
- Daniela Campaz-Landazábal
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - María-Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
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Hysong SJ, Giardina TD, Freytag J, SoRelle R, Murphy DR, Cully JA, Sada YH, Amspoker AB. Study protocol: maintaining preventive care during public health emergencies through effective coordination. Implement Sci Commun 2023; 4:150. [PMID: 38012710 PMCID: PMC10680205 DOI: 10.1186/s43058-023-00507-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/01/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Screening lies at the heart of preventive care. However, COVID-19 dramatically disrupted routine screening efforts, resulting in excess mortality not directly attributable to COVID-19. Screening rates during COVID varied markedly by facility and clinical condition, suggesting susceptibilities in screening and referral process workflow. To better understand these susceptibilities and identify new practices to mitigate interrupted care, we propose a qualitative study comparing facilities that exhibited high, low, and highly variable performance (respectively) in screening rates before and during the pandemic. We will be guided by Weaver et al.'s multi-team systems (MTS) model of coordination, using cancer and mental health screening rates as exemplars. METHOD Qualitative analysis of interviews and focus groups with primary care personnel, leadership, and patients at 10 VA medical centers. We will select sites based on rurality, COVID-19 caseload at the beginning of the pandemic, and performance on five outpatient clinical performance indicators of cancer and mental health screening. Sites will be categorized into one of five screening performance groups: high performers, low performers, improvers, plummeters, and highly variable. We will create process maps for each performance measure to create a workflow baseline and then interview primary care leadership to update the map at each site. We will clinician conduct focus groups to elicit themes regarding clinician coordination patterns (e.g., handoffs), strategies, and barriers/facilitators to screening during COVID. We will also conduct patient interviews to examine their screening experience during this period, for context. All interviews and focus groups will be audio-recorded, transcribed, and enhanced by field notes. We will analyze clinician transcripts and field notes using iterative, rapid analysis. Patient interviews will be analyzed using inductive/deductive content analysis. DISCUSSION Our study represents a unique opportunity to inform the multi-team systems literature by identifying specific forms of information exchange, collective problem solving, and decision-making associated with higher and improved clinical performance. Specifically, our study aims to detect the specific points in the screening and referral process most susceptible to disruption and coordination processes that, if changed, will yield the highest value. Findings apply to future pandemics or any event with the potential to disrupt care.
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Affiliation(s)
- Sylvia J Hysong
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.
- Department of Medicine - Health Services Research, Baylor College of Medicine, Houston, TX, USA.
| | - Traber Davis Giardina
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine - Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer Freytag
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine - Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Richard SoRelle
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine - Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Daniel R Murphy
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine - Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey A Cully
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Yvonne H Sada
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine - Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Amber B Amspoker
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine - Health Services Research, Baylor College of Medicine, Houston, TX, USA
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Cordasco KM, Gable AR, Ganz DA, Brunner JW, Smith AJ, Hertz B, Post EP, Fix GM. Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements. J Gen Intern Med 2023; 38:1007-1014. [PMID: 37798582 PMCID: PMC10593700 DOI: 10.1007/s11606-023-08285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/13/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.
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Affiliation(s)
- Kristina M Cordasco
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Alicia R Gable
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - David A Ganz
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Julian W Brunner
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Brian Hertz
- Edward Hines Jr. VA Hospital, Hines, IL, USA
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- VA Central Office, Washington, DC, USA
| | - Edward P Post
- VA Central Office, Washington, DC, USA
- Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gemmae M Fix
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law Policy & Management, Boston University School of Public Health, Boston, MA, USA
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Srinivasan AP, Sullivan E, Desai A, Adiele A, Bell S, Lion KC. Disparities in Pediatric Specialty Referral Scheduling and Completion. J Pediatr 2023; 260:113485. [PMID: 37196777 DOI: 10.1016/j.jpeds.2023.113485] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 04/13/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To estimate differences in scheduled and completed specialty referrals by race, ethnicity, language for care, and insurance type. STUDY DESIGN We studied a retrospective cohort of 38 334 specialty referrals to a large children's hospital between March 2019 and March 2021. We included referrals for patients with primary care clinics within 5 miles of the hospital. We examined whether the odds of and time to scheduled and completed referrals differed by patient sociodemographic characteristics. RESULTS Of all referrals, 62% were scheduled and 54% were completed. Referral completion rates were lower for patients with Black race (45%), Native Hawaiian/Pacific Islander race (48%), Spanish language (49%), and public insurance (47%). Odds of scheduled and completed referral were lower for Asian (aOR scheduled: 0.94, [95% CI: 0.89, 0.99]; aOR completed: 0.92 [0.87, 0.97]), Black (aOR scheduled: 0.86 [0.79, 0.94]; aOR completed: 0.80 [0.73, 0.87]), and publicly insured patients (aOR scheduled: 0.71 [0.66, 0.75]; aOR completed: 0.70 [0.66, 0.75]). Time to scheduled and completed referral was longer for Black (adjusted hazard ratio [aHR] scheduled: 0.93 [0.88, 0.98]; aHR completed: 0.93 [0.87, 0.99]) and publicly insured patients (aHR scheduled: 0.85 [0.82, 0.88]; aHR completed: 0.84 [0.80, 0.87]) and families with a language other than English (aHR scheduled: 0.66 [0.62, 0.70]; aHR completed: 0.92 [0.86, 0.99]). CONCLUSIONS Within a geographically homogenous pediatric population, the odds and time to scheduled and completed specialty referrals differed by sociodemographic characteristics, suggesting the effects of discrimination. To improve access equity, health care organizations need clear and consistent referral workflows and more comprehensive metrics for access.
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Affiliation(s)
- Anisha P Srinivasan
- Department of Pediatrics, MIND Institute, University of California, Davis, Sacramento, CA.
| | - Erin Sullivan
- Seattle Children's Hospital and Research Institute, Seattle, WA
| | - Arti Desai
- Seattle Children's Hospital and Research Institute, Seattle, WA; Department of Pediatrics, University of Washington, Seattle, WA
| | - Alicia Adiele
- Seattle Children's Hospital and Research Institute, Seattle, WA
| | - Shaquita Bell
- Seattle Children's Hospital and Research Institute, Seattle, WA; Department of Pediatrics, University of Washington, Seattle, WA
| | - K Casey Lion
- Seattle Children's Hospital and Research Institute, Seattle, WA; Department of Pediatrics, University of Washington, Seattle, WA
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Taymournejad A, Hosseini SM, Jafari M, Alimohammadzadeh K, Maher A. Identification of the factors affecting the referral system of veterans' health services: A scoping review. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2023; 12:255. [PMID: 37727409 PMCID: PMC10506785 DOI: 10.4103/jehp.jehp_69_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 02/21/2023] [Indexed: 09/21/2023]
Abstract
Referral in the health system is a systematic process for the optimal allocation of resources and improves the access of people in need of treatment services. Considering the vulnerability of the veterans and more medical needs in this group, this study aims to identify the components that affect veterans' health services referral system. MEDLINE, Scopus, Web of Science, and ProQuest databases, the international military studies website, and key journals in the field of veterans' health services were searched with related keywords including "veteran," "referral system," and "health services" for the period from January 2000 to July 2022. Studies were screened and selected in accordance with the phases of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) flow diagram 2020. Data extraction was done by two researchers independently and a thematic content analysis method was used to analyze the findings. Among 40,608 studies searched electronically and 16 studies searched manually, 19 studies that met the inclusion criteria were selected. The research method applied here is a combination of quantitative, qualitative, and mixed methods. The most important findings were extracted from the included studies and analyzed in three general categories: components related to the patient, service provider, and the structural-operational mechanisms of the referral system. The effective performance of the referral system for providing health services to veterans is influenced by the factors affecting components related to the patient, the service provider, and the structural-operational mechanisms of the referral system. Evaluating and improving each of these factors improve the performance of the referral system and provision of health services to veterans.
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Affiliation(s)
- Ahmad Taymournejad
- Health Services Management, North Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Seyed Mojtaba Hosseini
- Health Services Management Department, North Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Mehrnoosh Jafari
- Health Services Management Department, North Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Khalil Alimohammadzadeh
- Health Services Management Department, North Tehran Branch, Islamic Azad University, Tehran, Iran
- Economic Policy Research Center, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Ali Maher
- Department of Health Policy, Economics and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Aboelkhir HAB, Elomri A, ElMekkawy TY, Kerbache L, Elakkad MS, Al-Ansari A, Aboumarzouk OM, El Omri A. A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16952. [PMID: 36554837 PMCID: PMC9778793 DOI: 10.3390/ijerph192416952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process. METHODS A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis. RESULTS A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified. CONCLUSIONS Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
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Affiliation(s)
| | - Adel Elomri
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Tarek Y. ElMekkawy
- Department of Mechanical and Industrial Engineering, College of Engineering, Qatar University, Doha 2713, Qatar
| | - Laoucine Kerbache
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Mohamed S. Elakkad
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Abdulla Al-Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, QU-Health, Qatar University, Doha 2713, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Abdelfatteh El Omri
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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10
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Design and Implementation of Mental Health Consultation System for Primary and Secondary School Students Based on Credibility Matching Model. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2022; 2022:7986850. [PMID: 36133160 PMCID: PMC9484920 DOI: 10.1155/2022/7986850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022]
Abstract
Primary and secondary schools have the enormous responsibility of developing talent over a hundred years, and they should not only be concerned with the moral, ideological, and cultural development of teenagers but also with their mental well-being. We need to start by making the external environment better, provide in-depth psychological counseling, and support students as they work to continually increase their psychological adaptability in order to promote the healthy development of their personalities. As the epidemic situation in China has now stabilized into a normal state of prevention and control, it is imperative to provide primary and secondary school students with mental health education. In light of this context, this paper develops a browser-server network architecture-based consultation system for the mental health of students in primary and secondary schools. It eliminates the conventional booking mode and substitutes credibility as the characteristic programming parameter. The performance of the original system is improved by the reliability model the most when the parameter is set to 0.2, and the recovery rate rises by 1.32 percent. Compared to the original reliability model, which improved the system’s F value performance by 0.83 percent, the accuracy rate only declines by 0.68 percent while F rises by 0.37 percent. This research is crucial for creating an information campus and raising the standard of psychological counseling.
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11
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Economou MA, Kaiser BN, Yoeun SW, Crable EL, McMenamin SB. Applying the EPIS framework to policy-level considerations: Tobacco cessation policy implementation among California Medicaid managed care plans. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221096289. [PMID: 37091072 PMCID: PMC9924244 DOI: 10.1177/26334895221096289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background In 2016, the California Department of Healthcare Services (DHCS) released an "All Plan Letter" (APL 16-014) to its Medicaid managed care plans (MCPs) providing guidance on implementing tobacco-cessation coverage among Medicaid beneficiaries. However, implementation remains poor. We apply the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify barriers and facilitators to fidelity to APL 16-014 across California Medicaid MCPs. Methods We assessed fidelity through semi-structured interviews with MCP health educators (N = 24). Interviews were recorded, transcribed, and reviewed to develop initial themes regarding barriers and facilitators to implementation. Initial thematic summaries were discussed and mapped onto EPIS constructs. Results The APL (Innovation) was described as lacking clarity and specificity in its guidelines, hindering implementation. Related to the Inner Context, MCPs described the APL as beyond the scope of their resources, pointing to their own lack of educational materials, human resources, and poor technological infrastructure as implementation barriers. In the Outer Context, MCPs identified a lack of incentives for providers and beneficiaries to offer and participate in tobacco-cessation programs, respectively. A lack of communication, educational materials, and training resources between the state and MCPs (missing Bridging Factors) were barriers to preventing MCPs from identifying smoking rates or gauging success of tobacco-cessation efforts. Facilitators included several MCPs collaborating with each other and using external resources to promote tobacco cessation. Additionally, a few MCPs used fidelity monitoring staff as Bridging Factors to facilitate provider training, track providers' identification of smokers, and follow-up with beneficiaries participating in tobacco-cessation programs. Conclusions The release of the evidence-based APL 16-014 by California's DHCS was an important step forward in promoting tobacco-cessation services for Medicaid MCP beneficiaries. Improved communication on implementation in different environments and improved Bridging Factors such as incentives for providers and patients are needed to fully realize policy goals. Plan Language Summary In 2016, the California Department of Healthcare Services (DHCS) in California released an "All Plan Letter" (APL 16-014) to its Medicaid managed care plans (MCPs) providing guidance on implementing tobacco-cessation coverage to address tobacco use among Medicaid beneficiaries. We conducted semi-structured interviews with health educators in California Medicaid MCPs to explore the barriers and facilitators to implementing the APL using the Exploration, Preparation, Implementation, Sustainment framework. According to MCPs, barriers included a lack of clarity in the APL guidelines; a lack of resources, including educational materials, infrastructure to identify smokers, and human resources; and a lack of incentives or penalties for providers to provide tobacco-cessation materials to beneficiaries. Facilitators included collaboration between MCPs and state and/or national public health programs. Overall, our findings can provide avenues for improving the implementation of tobacco-cessation services within Medicaid MCPs.
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Affiliation(s)
- Melina A. Economou
- Department of Anthropology, University of California, San Diego, CA,
USA
| | - Bonnie N. Kaiser
- Department of Anthropology, University of California, San Diego, CA,
USA
- Global Health Program, University of California, San Diego, CA,
USA
- UC San Diego ACTRI Dissemination and
Implementation Science Center, San Diego, CA, USA
| | - Sara W. Yoeun
- Herbert Wertheim School of Public Health, University of California,
San Diego, CA, USA
| | - Erika L. Crable
- UC San Diego ACTRI Dissemination and
Implementation Science Center, San Diego, CA, USA
- Department of Psychiatry, University of California, San Diego, CA,
USA
| | - Sara B. McMenamin
- Herbert Wertheim School of Public Health, University of California,
San Diego, CA, USA
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12
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Fantasia KL, Stockman MC, Ju Z, Ortega P, Crable EL, Drainoni ML, Walkey AJ, Bergstrom M, O'Brien K, Steenkamp D. Professional continuous glucose monitoring and endocrinology eConsult for adults with type 2 diabetes in primary care: Results of a clinical pilot program. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2021; 24:100254. [PMID: 33898271 PMCID: PMC8054187 DOI: 10.1016/j.jcte.2021.100254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/03/2021] [Accepted: 03/25/2021] [Indexed: 11/30/2022]
Abstract
Background Limitations in access to specialty diabetes care exist. Endocrinology eConsult that integrates professional continuous glucose monitoring (CGM-enhanced eConsult) may improve healthcare delivery, but has yet to be evaluated. We implemented a pilot program for patients with type 2 diabetes (T2DM) managed by primary care clinical pharmacists using CGM-enhanced eConsult and evaluated the acceptability and clinical outcomes in comparison to routine in-person endocrinology consultation. Methods Seventy-four adult patients with established T2DM (age 18-65) were included. Twenty-nine were seen in-person by endocrinology and 45 were seen by pharmacists in primary care. Thirteen patients were referred for CGM-enhanced eConsult. Acceptability was assessed with pre/post clinician acceptability questionnaires and patient assessment of perceived burden. Clinical outcomes included time to first specialty appointment, baseline and 3-month follow-up HbA1c, and antihyperglycemic medication use. Results There were no differences in patient acceptability of the CGM-enhanced eConsult as compared to endocrinology referral or pharmacy care. At baseline, all patients referred for eConsult were prescribed insulin. Three-month glycemic outcomes were comparable, with HbA1c reduction 1% + 2% in endocrinology, 1.5% + 1.1% with CGM-enhanced eConsult, and 1.6% + 1.8% in clinical pharmacy (p = 0.19). Time to an initial diabetes visit with a pharmacist was significantly shorter than with endocrinology, 20 days (IQR 26) for pharmacy vs. 45 days (IQR 54) for endocrinology, (p = 0.0001). Conclusions CGM-enhanced eConsult resulted in more timely access to endocrinology expertise, was acceptable to patients, and resulted in similar short-term glycemic outcomes compared to in-person consultation. Effectiveness of CGM-enhanced eConsults should be further explored.
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Key Words
- BMC, Boston Medical Center
- BMI, Body mass index
- CGM, Continuous glucose monitoring
- Certified diabetes educators
- DPP-4, Dipeptidyl peptidase-4
- Diabetes mellitus, type 2
- ED, Emergency department
- EMR, Electronic medical record
- GLP-1 RA, glucagon-like peptide-1 receptor agonist
- HbA1c, Hemoglobin A1c
- IQR, Interquartile range
- Pharmacists
- Professional continuous glucose monitoring
- Referral and consultation
- eConsult, Electronic consultation
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Affiliation(s)
- Kathryn L Fantasia
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
| | - Mary-Catherine Stockman
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
| | - Zhihui Ju
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
| | - Paola Ortega
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
| | - Erika L Crable
- Boston University School of Medicine, Department of Medicine, Evans Center for Implementation and Improvement Sciences, United States.,Boston University School of Public Health, Department of Health Law, Policy & Management, United States
| | - Mari-Lynn Drainoni
- Boston University School of Medicine, Department of Medicine, Evans Center for Implementation and Improvement Sciences, United States.,Boston University School of Medicine, Department of Medicine, Section of Infectious Diseases, United States.,Boston University School of Public Health, Department of Health Law, Policy & Management, United States
| | - Allan J Walkey
- Boston University School of Medicine, Department of Medicine, Evans Center for Implementation and Improvement Sciences, United States.,Boston University School of Public Health, Department of Health Law, Policy & Management, United States.,Boston University School of Medicine, Department of Medicine, The Pulmonary Center, United States
| | - Megan Bergstrom
- Boston Medical Center, Department of Pharmacy, Section of General Internal Medicine, United States
| | - Katelyn O'Brien
- Boston Medical Center, Department of Pharmacy, Section of General Internal Medicine, United States
| | - Devin Steenkamp
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
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Weiner M, Savoy A, Barker BC. Gains, losses, and uncertainties from computerizing referrals and consultations. APPLIED ERGONOMICS 2020; 89:103227. [PMID: 32768721 PMCID: PMC7484235 DOI: 10.1016/j.apergo.2020.103227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/10/2020] [Accepted: 07/20/2020] [Indexed: 06/11/2023]
Abstract
Consultations entail transitions in care between referrers and consultants, as patients visit different clinicians and care sites. This complex process has been consistently prone to communication breakdowns. Despite expectations and benefits of electronic health records (EHRs), incomplete, vague, or inappropriate referrals continue to hinder consultations; referrals can be sent to the wrong specialty service; and consultation findings frequently fail to reach referrers. Due to the inadequate support of interpersonal communication afforded by EHRs, these issues persist. Important aspects of ergonomics and human factors engineering frequently appear overlooked during the design and implementation of EHRs. Usability issues have contributed to delays in medical diagnosis, treatment, and follow-up. Some of these delays contribute to patient harms. Our multidisciplinary team of clinicians and ergonomics professionals reflects on referral and consultation. We describe how computerization in healthcare should benefit from approaches informed and developed through applied ergonomics and human factors.
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Affiliation(s)
- Michael Weiner
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University Center for Health Services and Outcomes Research, Indianapolis, IN, USA
| | - April Savoy
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University Center for Health Services and Outcomes Research, Indianapolis, IN, USA; Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indiana, USA.
| | - Barry C Barker
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
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14
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Odisho AY, Lui H, Yerramsetty R, Bautista F, Gleason N, Martin E, Young JJ, Blum M, Neinstein AB. Design and development of referrals automation, a SMART on FHIR solution to improve patient access to specialty care. JAMIA Open 2020; 3:405-412. [PMID: 33215075 PMCID: PMC7660949 DOI: 10.1093/jamiaopen/ooaa036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/08/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022] Open
Abstract
Background Referring patients to specialty care is an inefficient and error-prone process. Gaps in the referral process lead to delays in patients' access to care, negative patient experience, worse health outcomes, and increased operational costs. While implementation of standards-based electronic referral options can alleviate some of these inefficiencies, many referrals to tertiary and quaternary care centers continue to be sent via fax. Objective We describe the design process and architecture for a software application that has been developed and deployed to optimize the referrals intake process by automating the processing and digitization of incoming specialty referral faxes, extracting key data elements and integrating them into the electronic health record (EHR), and organizing referrals. Methods A human-centered design approach was used to identify and describe the inefficiencies in the external referral process at our large, urban tertiary care center. Referrals Automation, an application to convert referral faxes to digital referrals in the EHR, was conceptualized based on key stakeholder interviews and time and motion studies. This application was designed using Substitutable Medical Applications and Reusable Technologies (SMART) and Fast Healthcare Interoperability Resource (FHIR) platforms to allow for adaptability into other healthcare organizations. Results Referrals Automation software was developed as a healthcare information technology solution to streamline the fax to referral process. The application was implemented into several specialty clinics. Metrics were built-in to the applications to evaluate and guide the further iteration of these features. Conclusions Referrals Automation will enhance the referrals process by further streamlining and organizing the patient referral process.
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Affiliation(s)
- Anobel Y Odisho
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA.,Department of Urology, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Hansen Lui
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ramakrishna Yerramsetty
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA
| | - Felicisimo Bautista
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA
| | - Nathaniel Gleason
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA.,Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Edwin Martin
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA
| | - Jerry J Young
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA
| | - Michael Blum
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA.,Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aaron B Neinstein
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, California, USA.,Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, California, USA
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15
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Vimalananda VG, Meterko M, Qian S, Wormwood JB, Solch MSW A, Fincke BG. Development and psychometric assessment of a survey to measure specialty care coordination as experienced by primary care providers. Health Serv Res 2020; 55:660-670. [PMID: 33460075 PMCID: PMC7518815 DOI: 10.1111/1475-6773.13310] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To assess the psychometric properties and construct validity of a survey of primary care providers' (PCPs') experience of specialty care coordination, which is a counterpart to our existing survey ("CSC-Specialist") that measures specialists' experience of specialty care coordination. DATA SOURCES We surveyed PCPs from Veterans Health Administration medical centers and community-based outpatient clinics nationwide (N = 1576) in April 2018. STUDY DESIGN We developed candidate items through literature review, existing surveys, PCP interviews, and expert opinion. We used exploratory and confirmatory factor analysis to develop scales and multivariable linear regression to determine their association with PCPs' overall experience of coordination. DATA COLLECTION The online survey included 23 candidate scale items about specialty care coordination and a single item asking respondents to rate their overall experience of specialty care coordination on a 0-10 scale. All VA PCPs were eligible. We sent survey invitations to PCPs following local Section Chiefs' email introduction (N = 926) and by directly emailing two random samples (N = 400 and N = 6653), overall response rate across the three nonoverlapping samples = 24 percent. PRINCIPAL FINDINGS Analyses identified 20 items forming 6 scales with strong psychometric properties and predictive power for overall coordination. Two scales are identical to CSC-Specialist scales: "Communication" (k = 3, α = 0.87) and "Data Transfer" (k = 2, α = 0.92); one is similar: "Relationships and Collaboration" (k = 6, α = 0.90). The three remaining scales address the PCP's unique perspective: "Role Clarity" (k = 3, α = 0.85), "Role Agreement" (k = 3, α = 0.75), and "Making Referrals" (k = 3, α = 0.75). The six scales together explained 67 percent of the variance in PCPs' overall coordination experience with specialists. CONCLUSIONS The Coordination of Specialty Care-Primary Care Provider Survey (CSC-PCP) is a novel 20-item survey that can be used in quality improvement or health services research, alone or in combination with the CSC-Specialist, to evaluate coordination of care as experienced by either or both participants.
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Affiliation(s)
- Varsha G. Vimalananda
- Center for Healthcare Organization and Implementation Research (CHOIR)Edith Nourse Rogers Memorial VA Medical CenterBedfordMassachusettsUSA
- Section of Endocrinology, Diabetes and MetabolismBoston University School of MedicineBostonMassachusettsUSA
| | - Mark Meterko
- VHA Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID – 10EA)Field‐Based at the Edith Nourse Rogers Memorial VA Medical CenterBedfordMassachusettsUSA
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
| | - Shirley Qian
- Center for Healthcare Organization and Implementation Research (CHOIR)Edith Nourse Rogers Memorial VA Medical CenterBedfordMassachusettsUSA
| | - Jolie B. Wormwood
- Center for Healthcare Organization and Implementation Research (CHOIR)Edith Nourse Rogers Memorial VA Medical CenterBedfordMassachusettsUSA
- Department of PsychologyUniversity of New HampshireDurhamNew HampshireUSA
| | - Amanda Solch MSW
- Center for Healthcare Organization and Implementation Research (CHOIR)Edith Nourse Rogers Memorial VA Medical CenterBedfordMassachusettsUSA
| | - Benjamin Graeme Fincke
- Center for Healthcare Organization and Implementation Research (CHOIR)Edith Nourse Rogers Memorial VA Medical CenterBedfordMassachusettsUSA
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
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16
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Competencies to promote collaboration between primary and secondary care doctors: an integrative review. BMC FAMILY PRACTICE 2020; 21:179. [PMID: 32878620 PMCID: PMC7469099 DOI: 10.1186/s12875-020-01234-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 07/29/2020] [Indexed: 12/02/2022]
Abstract
Background In a society where ageing of the population and the increasing prevalence of long-term conditions are major issues, collaboration between primary and secondary care is essential to provide continuous, patient-centred care. Doctors play an essential role at the primary-secondary care interface in realising ‘seamless’ care. Therefore, they should possess collaborative competencies. However, knowledge about these collaborative competencies is scarce. In this review we explore what competencies doctors need to promote collaboration between doctors at the primary-secondary care interface. Methods We conducted an integrative literature review. After a systematic search 44 articles were included in the review. They were analysed using a thematic analysis approach. Results We identified six themes regarding collaborative competencies: ‘patient-centred care: a common concern’, ‘roles and responsibilities’, ‘mutual knowledge and understanding’, ‘collaborative attitude and respect’, ‘communication’ and ‘leadership’. In every theme we specified components of knowledge, skills and attitudes as found in the reviewed literature. The results show that doctors play an important role, not only in the way they collaborate in individual patient care, but also in how they help shaping organisational preconditions for collaboration. Conclusions This review provides an integrative view on competencies necessary for collaborative practice at the primary-secondary care interface. They are part of several domains, showing the complexity of collaboration. The information gathered in this review can support doctors to enhance and learn collaboration in daily practice and can be used in educational programmes in all stages of medical education.
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17
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Slavin MJ, Rajan M, Kern LM. Internal medicine residents identify gaps in medical education on outpatient referrals. BMC MEDICAL EDUCATION 2020; 20:243. [PMID: 32731856 PMCID: PMC7392837 DOI: 10.1186/s12909-020-02177-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/24/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Relevant clinical information is often missing when a patient sees a specialist after being referred by another physician in the ambulatory setting. This can result in missed or delayed diagnoses, delayed treatment, unnecessary testing, and drug interactions. Residents' attitudes toward providing clinical information at the time of referral and their perspectives toward training on referral skills are not clear. We sought to assess internal medicine residents' attitudes toward and experiences with outpatient referrals. METHODS We conducted a cross-sectional survey in October-December 2018 of all internal medicine interns and residents affiliated with a large, urban internal medicine residency program in New York, NY. We used a novel survey instrument that included 13 questions about attitudes toward and experiences with outpatient referrals. We used descriptive statistics to characterize the results. RESULTS Overall, 122 of 132 residents participated (92% response rate). Respondents were approximately equally distributed across post-graduate years 1-3. Although 83% of residents reported that it is "always" important to provide the clinical reason for a referral, only 11% stated that they "always" provide a sufficient amount of clinical information for the consulting provider when making a referral. Only 9% of residents "strongly agree" that residency provides sufficient training in knowing when to refer patients, and only 8% "strongly agree" that residency provides sufficient training in what information to provide the consulting physician. CONCLUSIONS These results suggest a substantial discrepancy between the amount of information residents believe they should provide at the time of a referral and the amount they actually provide. Many residents report not receiving adequate training during residency on when to refer patients and what clinical information to provide at the time of referral. Improvements to medical education regarding outpatient referrals are urgently needed.
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Affiliation(s)
| | | | - Lisa M Kern
- Weill Cornell Medicine, New York, NY, 10021, USA.
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Singh H, Sittig DF. A Sociotechnical Framework for Safety-Related Electronic Health Record Research Reporting: The SAFER Reporting Framework. Ann Intern Med 2020; 172:S92-S100. [PMID: 32479184 DOI: 10.7326/m19-0879] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Electronic health record (EHR)-based interventions to improve patient safety are complex and sensitive to who, what, where, why, when, and how they are delivered. Success or failure depends not only on the characteristics and behaviors of individuals who are targeted by an intervention, but also on the technical characteristics of the intervention and the culture and environment of the health system that implements it. Current reporting guidelines do not capture the complexity of sociotechnical factors (technical and nontechnical factors, such as workflow and organizational issues) that confound or influence these interventions. This article proposes a methodological reporting framework for EHR interventions targeting patient safety and builds on an 8-dimension sociotechnical model previously developed by the authors for design, development, implementation, use, and evaluation of health information technology. The Safety-related EHR Research (SAFER) Reporting Framework enables reporting of patient safety-focused EHR-based interventions while accounting for the multifaceted, dynamic sociotechnical context affecting intervention implementation, effectiveness, and generalizability. As an example, an EHR-based intervention to improve communication and timely follow-up of subcritical abnormal test results to operationalize the framework is presented. For each dimension, reporting should include what sociotechnical changes were made to implement an EHR-related intervention to improve patient safety, why the intervention did or did not lead to safety improvements, and how this intervention can be applied or exported to other health care organizations. A foundational list of research and reporting recommendations to address implementation, effectiveness, and generalizability of EHR-based interventions needed to effectively reduce preventable patient harm is provided. The SAFER Reporting Framework is not meant to replace previous research reporting guidelines, but rather provides a sociotechnical adjunct that complements their use.
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Affiliation(s)
- Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas (H.S.)
| | - Dean F Sittig
- University of Texas Memorial Hermann Center for Healthcare Quality & Safety, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Texas (D.F.S.)
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Abstract
EXECUTIVE SUMMARY Organizing patient care and improving team coordination have been identified by the Institute of Medicine and the Agency for Healthcare Research and Quality as essential components of high-quality care. Research is lacking, however, on the measurement of care team coordination and its mechanisms. Using an organizational psychology framework developed by Okhuysen and Bechky (O&B) as a guide, the authors identify strengths and gaps in the existing literature related to the measurement of coordination and its associated constructs. The authors conducted a review of peer-reviewed articles in healthcare, management, and psychology journals that contain survey items that could be used to measure the domains in the O&B framework. An initial search yielded 468 articles published from 1978 to 2014, 37 of which came from healthcare journals. From this set, 1,401 candidate survey items were extracted from 74 articles. Of these, 279 items were categorized into at least one O&B domain. Retained items were drawn from scales representing 51 constructs related to teamwork, roles, trust, coordination broadly, and ancillary constructs. Two constructs, physical proximity and plans and rules, were directly represented both in the O&B framework and as standalone constructs in the literature. The remaining constructs contributed items that indirectly assess components of the O&B framework domains. Despite decades of research on coordination, valid survey items for measuring the mechanisms and integrating conditions described by the O&B framework as leading to successful team coordination are scarce, and virtually nonexistent in healthcare, as measures of care team coordination.
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Gilani S, Bommakanti K, Friedman L. Electronic Consults in Otolaryngology: A Pilot Study to Evaluate the Use, Content, and Outcomes in an Academic Health System. Ann Otol Rhinol Laryngol 2019; 129:170-174. [PMID: 31625409 DOI: 10.1177/0003489419882726] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To categorize the primary reasons for electronic consults (eConsults) to otolaryngology from primary care physicians (PCPs). To determine how many patients avoided subsequent in-person otolaryngology office visits. METHODS This is a retrospective analysis of a pilot study that took place between 2016 and 2017 regarding eConsults to adult otolaryngology placed by primary care physicians at the University of California, San Diego (UCSD) Medical Center. The complaints were categorized as related to the following: ear, nose, throat or neck. Initial recommendations were classified as (1) providing education only (no intervention), (2) suggesting medical therapy provided by the PCP, or (3) suggesting surgical intervention. Univariate statistics and multinomial logistic regression were used to analyze the association of problem type with the need for follow-up in the otolaryngology offices. The data was analyzed for differences in patient age and gender. RESULTS The study population included 64 patients (average age 54.6 years, 60.9% male). Within this group, 41% of consults were for ear complaints, 15% for nose complaints, 28% had throat-related complaints, and 16% had neck-related complaints. In-person follow-up was not required for 82.8% of the consults. Overall, 76.9% of ear, 100% of nose, 88.9% of throat, and 70.0% of neck complaints did not require in-person visits. CONCLUSIONS eConsults to otolaryngology were primarily for ear concerns. Of the eConsults, 82.4% did not require in-person follow-up. We therefore conclude that the use of eConsults prevented substantial office visits that would not otherwise be necessary. Efforts should be made to promote the widespread use of eConsults, which may to the more efficient use of resources.
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Affiliation(s)
- Sapideh Gilani
- Department of Surgery, Division of Head and Neck Surgery, University of California San Diego, San Diego, CA, USA
| | - Krishna Bommakanti
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Lawrence Friedman
- Department of Internal Medicine, University of California San Diego, San Diego, CA, USA
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21
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Bettano A, Land T, Byrd A, Svencer S, Nasuti L. Using Electronic Referrals to Address Health Disparities and Improve Blood Pressure Control. Prev Chronic Dis 2019; 16:E114. [PMID: 31441768 PMCID: PMC6716462 DOI: 10.5888/pcd16.180583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Massachusetts developed and used bidirectional electronic referrals to connect clinical patients across the state to interventions run by community organizations. The objective of our study was to determine whether the use of Massachusetts’s electronic referral system (MA e-Referral) reached racial/ethnic groups experiencing health disparities and whether it was associated with improved health outcomes. Methods We assembled encounter-level medical records from September 2013 through June 2017 for patients at Massachusetts clinics funded by the Clinical Community Partnerships for Prevention into 2 cohorts. First, all patients meeting program eligibility guidelines for an e-Referral (N = 21,701) were examined to assess the distribution of e-Referrals among populations facing health disparities; second, a subset of 3,817 people with hypertension were analyzed to detect changes in blood pressure after e-Referral to an evidence-based community intervention. Results Non-Hispanic black (OR, 1.4; 95% confidence interval [CI], 1.2–1.6) and Hispanic patients (OR, 1.3; 95% CI, 1.1–1.4) had higher odds than non-Hispanic white patients of being referred electronically. Patients completing their hypertension intervention had 74% (95% CI, 1.2–2.5) higher odds of having an in-control blood pressure reading than patients who were not electronically referred. Conclusion Clinical to community linkage to interventions through MA e-Referral reached non-Hispanic black, Hispanic, and Spanish-speaking populations and was associated with improved blood pressure control.
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Affiliation(s)
- Amy Bettano
- Massachusetts Department of Public Health, 250 Washington St, 6th floor, Boston, MA 02108.
| | - Thomas Land
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Alice Byrd
- Massachusetts Department of Public Health, Boston, Massachusetts
| | - Susan Svencer
- National Association of Chronic Disease Directors, Decatur, Georgia
| | - Laura Nasuti
- Massachusetts Department of Public Health, Boston, Massachusetts
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22
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Vimalananda VG, Fincke BG, Qian S, Waring ME, Seibert RG, Meterko M. Development and psychometric assessment of a novel survey to measure care coordination from the specialist's perspective. Health Serv Res 2019; 54:689-699. [PMID: 30941764 DOI: 10.1111/1475-6773.13148] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To develop an online survey of care coordination with primary care providers as experienced by medical specialists, evaluate its psychometric properties, and test its construct validity. DATA SOURCES Physicians (N = 633) from 13 medical specialties across the Veterans Health Administration. STUDY DESIGN We developed the survey based on prior work (literature review, specialist interviews) and by adapting existing measures and developing new items. Multitrait scaling analysis and confirmatory factor analysis were used to assess scale structure. We used multiple linear regression to examine the relationship of the final coordination scales to specialists' overall experience of care coordination. DATA COLLECTION November 2016-December 2016. PRINCIPAL FINDINGS Results suggest a 13-item, four-factor survey [Relationships (k = 4), Roles and Responsibilities (k = 4), Communication (k = 3), and Data Transfer (k = 2)] that measures the medical specialist experience of coordination with good internal consistency reliability, convergent validity, discriminant validity, and goodness of fit. Together, the four scales explained nearly 50 percent of the variance in specialists' overall experience of care coordination. CONCLUSIONS The 13-item Coordination of Specialty Care-Specialist Survey (CSC-Specialist) is the first of its kind. It can be used alone or embedded in other surveys to measure four domains of care coordination as experienced by medical specialists.
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Affiliation(s)
- Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford, Massachusetts.,Section of Endocrinology, Diabetes and Metabolism, Boston University School of Medicine, Boston, Massachusetts
| | - Benjamin Graeme Fincke
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford, Massachusetts.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Shirley Qian
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford, Massachusetts
| | - Molly E Waring
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford, Massachusetts.,Department of Allied Health Sciences, College of Agriculture, Health, and Natural Resources, University of Connecticut, Storrs, Connecticut
| | - Ryan G Seibert
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Mark Meterko
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts.,VHA Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID - 10EA), Field-based at the Edith Nourse Rogers Memorial VA Medical Center, Bedford, Massachusetts
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23
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Savoy A, Patel H, Flanagan ME, Daggy JK, Russ AL, Weiner M. Comparative usability evaluation of consultation order templates in a simulated primary care environment. APPLIED ERGONOMICS 2018; 73:22-32. [PMID: 30098639 DOI: 10.1016/j.apergo.2018.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 02/12/2018] [Accepted: 05/27/2018] [Indexed: 06/08/2023]
Abstract
Communication breakdowns in the referral process negatively impact clinical workflow and patient safety. There is a lack of evidence demonstrating the impact of published design recommendations addressing contributing issues with consultation order templates. This study translated the recommendations into a computer-based prototype and conducted a comparative usability evaluation. With a scenario-based simulation, 30 clinicians (referrers) participated in a within-group, counterbalanced experiment comparing the prototype with their present electronic order entry system. The prototype significantly increased satisfaction (Cohen's d = 1.80, 95% CI [1.19, 2.41], p < .001), and required significantly less mental effort (d = 0.67 [0.14, 1.20], p < .001). Regarding efficiency, the prototype required significantly fewer mouse clicks (mean difference = 29 clicks, p < .001). Although overall task time did not differ significantly (d = -0.05 [-0.56, 0.47]), the prototype significantly quickened identification of the appropriate specialty clinic (mean difference = 12 s, d = 0.98 [0.43, 1.52], p < .001). The experimental evidence demonstrated that clinician-centered interfaces significantly improved system usability during ordering of consultations.
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Affiliation(s)
- April Savoy
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA;; Regenstrief Institute, Inc., Indianapolis, IN, USA; School of Business and Economics, Indiana University East, Richmond, IN, USA.
| | - Himalaya Patel
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | | | - Joanne K Daggy
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alissa L Russ
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA;; Regenstrief Institute, Inc., Indianapolis, IN, USA; College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Michael Weiner
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA;; Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
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24
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Klingberg A, Wallis LA, Hasselberg M, Yen PY, Fritzell SC. Teleconsultation Using Mobile Phones for Diagnosis and Acute Care of Burn Injuries Among Emergency Physicians: Mixed-Methods Study. JMIR Mhealth Uhealth 2018; 6:e11076. [PMID: 30341047 PMCID: PMC6231743 DOI: 10.2196/11076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/18/2018] [Accepted: 07/18/2018] [Indexed: 02/01/2023] Open
Abstract
Background The referral process in acute care remains challenging in many areas including burn care. Mobile phone apps designed explicitly for medical referrals and consultations could streamline the referral process by using structured templates and integrating features specific to different specialties. However, as these apps are competing with commercial chat services, usability becomes a crucial factor for successful uptake. Objective The aim of this study was to assess the usability of a mobile phone app for remote consultations and referrals of burn injuries. Methods A total of 24 emergency doctors and 4 burns consultants were recruited for the study. A mixed-methods approach was used including a usability questionnaire and a think-aloud interview. Think-aloud sessions were video-recorded, and content analysis was undertaken with predefined codes relating to the following 3 themes: ease of use, usefulness of content, and technology-induced errors. Results The users perceived the app to be easy to use and useful, but some problems were identified. Issues relating to usability were associated with navigation, such as scrolling and zooming. Users also had problems in understanding the meaning of some icons and terminologies. Sometimes, some users felt limited by predefined options, and they wanted to be able to freely express their clinical findings. Conclusions We found that users faced problems mainly with navigation when the app did not work in the same way as the other apps that were frequently used. Our study also resonates with previous findings that when using standardized templates, the systems should also allow the user to express their clinical findings in their own words.
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Affiliation(s)
- Anders Klingberg
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Lee Alan Wallis
- Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marie Hasselberg
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Po-Yin Yen
- Institute for Informatics, Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States.,Goldfarb School of Nursing, Barnes-Jewish College, St. Louis, MO, United States
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25
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Savoy A, Militello LG, Patel H, Flanagan ME, Russ AL, Daggy JK, Weiner M, Saleem JJ. A cognitive systems engineering design approach to improve the usability of electronic order forms for medical consultation. J Biomed Inform 2018; 85:138-148. [DOI: 10.1016/j.jbi.2018.07.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 06/19/2018] [Accepted: 07/29/2018] [Indexed: 12/30/2022]
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Patient, Primary Care Provider, and Specialist Perspectives on Specialty Care Coordination in an Integrated Health Care System. J Ambul Care Manage 2018; 41:15-24. [PMID: 29176459 DOI: 10.1097/jac.0000000000000219] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists-that is, the specialty care "triad." This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and endocrinologists relied on interclinician relationships to coordinate care. Clinicians rarely included patients or other staff in their conceptualization of specialty care coordination. Patients often assumed responsibility for specialty care coordination but struggled to succeed. We identified several opportunities to improve coordination across the triad. In an integrated medical system, the shared organizational structure can facilitate these efforts.
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27
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Expanding the Capacity of Primary Care to Treat Co-morbidities in Children with Autism Spectrum Disorder. J Autism Dev Disord 2018; 48:4222-4230. [DOI: 10.1007/s10803-018-3630-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Rosen MA, DiazGranados D, Dietz AS, Benishek LE, Thompson D, Pronovost PJ, Weaver SJ. Teamwork in healthcare: Key discoveries enabling safer, high-quality care. AMERICAN PSYCHOLOGIST 2018; 73:433-450. [PMID: 29792459 PMCID: PMC6361117 DOI: 10.1037/amp0000298] [Citation(s) in RCA: 441] [Impact Index Per Article: 73.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Few industries match the scale of health care. In the United States alone, an estimated 85% of the population has at least 1 health care encounter annually and at least one quarter of these people experience 4 to 9 encounters annually. A single visit requires collaboration among a multidisciplinary group of clinicians, administrative staff, patients, and their loved ones. Multiple visits often occur across different clinicians working in different organizations. Ineffective care coordination and the underlying suboptimal teamwork processes are a public health issue. Health care delivery systems exemplify complex organizations operating under high stakes in dynamic policy and regulatory environments. The coordination and delivery of safe, high-quality care demands reliable teamwork and collaboration within, as well as across, organizational, disciplinary, technical, and cultural boundaries. In this review, we synthesize the evidence examining teams and teamwork in health care delivery settings in order to characterize the current state of the science and to highlight gaps in which studies can further illuminate our evidence-based understanding of teamwork and collaboration. Specifically, we highlight evidence concerning (a) the relationship between teamwork and multilevel outcomes, (b) effective teamwork behaviors, (c) competencies (i.e., knowledge, skills, and attitudes) underlying effective teamwork in the health professions, (d) teamwork interventions, (e) team performance measurement strategies, and (f) the critical role context plays in shaping teamwork and collaboration in practice. We also distill potential avenues for future research and highlight opportunities to understand the translation, dissemination, and implementation of evidence-based teamwork principles into practice. (PsycINFO Database Record
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Affiliation(s)
- Michael A Rosen
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - Deborah DiazGranados
- Office of Assessment and Evaluation Studies, Virginia Commonwealth University School of Medicine
| | - Aaron S Dietz
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - Lauren E Benishek
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - David Thompson
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - Peter J Pronovost
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - Sallie J Weaver
- Health Systems and Interventions Research Branch of the Healthcare Delivery Research Program, National Cancer Institute
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29
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Aller MB, Vargas I, Coderch J, Vázquez ML. Doctors' opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system. BMC Health Serv Res 2017; 17:842. [PMID: 29273045 PMCID: PMC5741878 DOI: 10.1186/s12913-017-2690-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 11/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical coordination is considered a health policy priority as its absence can lead to poor quality of care and inefficiency. A key challenge is to identify which strategies should be implemented to improve coordination. The aim is to analyse doctors' opinions on the contribution of mechanisms to improving clinical coordination between primary and outpatient secondary care and the factors influencing their use. METHODS A qualitative descriptive study in three healthcare networks of the Catalan national health system. A two-stage theoretical sample was designed: in the first stage, networks with different management models were selected; in the second, primary care (n = 26) and secondary care (n = 24) doctors. Data were collected using semi-structured interviews. Final sample size was reached by saturation. A thematic content analysis was conducted, segmented by network and care level. RESULTS With few differences across networks, doctors identified similar mechanisms contributing to clinical coordination: 1) shared EMR facilitating clinical information transfer and uptake; 2) mechanisms enabling problem-solving communication and agreement on clinical approaches, which varied across networks (joint clinical case conferences, which also promote mutual knowledge and training of primary care doctors; virtual consultations through EMR and email); and 3) referral protocols and use of the telephone facilitating access to secondary care after referrals. Doctors identified organizational (insufficient time, incompatible timetables, design of mechanisms) and professional factors (knowing each other, attitude towards collaboration, concerns over misdiagnosis) that influence the use of mechanisms. DISCUSSION Mechanisms that most contribute to clinical coordination are feedback mechanisms, that is those based on mutual adjustment, that allow doctors to exchange information and communicate. Their use might be enhanced by focusing on adequate working conditions, mechanism design and creating conditions that promote mutual knowledge and positive attitudes towards collaboration.
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Affiliation(s)
- Marta-Beatriz Aller
- Health Policy and Health Services Research Group; Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, 08022 Barcelona, Spain
| | - Ingrid Vargas
- Health Policy and Health Services Research Group; Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, 08022 Barcelona, Spain
| | - Jordi Coderch
- Grup de Recerca en Serveis Sanitaris i Resultats en Salut; Serveis de Salut Integrats Baix Empordà, Hospital, 17-19 Edif. Fleming, 17230 Palamós, Spain
| | - Maria-Luisa Vázquez
- Health Policy and Health Services Research Group; Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, 08022 Barcelona, Spain
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Improving quality of referral letters from primary to secondary care: a literature review and discussion paper. Prim Health Care Res Dev 2017; 19:211-222. [PMID: 29212565 DOI: 10.1017/s1463423617000755] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Referral letters sent from primary to secondary or tertiary care are a crucial element in the continuity of patient information transfer. Internationally, the need for improvement in this area has been recognised. This aim of this study is to review the current literature pertaining to interventions that are designed to improve referral letter quality. METHODS A search strategy designed following a Problem, Intervention, Comparator, Outcome model was used to explore the PubMed and EMBASE databases for relevant literature. Inclusion and exclusion criteria were established and bibliographies were screened for relevant resources. RESULTS A total of 18 publications were included in this study. Four types of interventions were described: electronic referrals were shown to have several advantages over paper referrals but were also found to impose new barriers; peer feedback increases letter quality and can decrease 'inappropriate referrals' by up to 50%; templates increase documentation and awareness of risk factors; mixed interventions combining different intervention types provide tangible improvements in content and appropriateness. CONCLUSION Several methodological considerations were identified in the studies reviewed but our analysis demonstrates that a combination of interventions, introduced as part of a joint package and involving peer feedback can improve.
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31
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Systematic Heuristic Evaluation of Computerized Consultation Order Templates: Clinicians’ and Human Factors Engineers’ Perspectives. J Med Syst 2017; 41:129. [DOI: 10.1007/s10916-017-0775-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 07/09/2017] [Indexed: 01/17/2023]
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Chollette V, Beasley DD, Abdiwahab E, Taplin S. Health Information Systems Approach to Managing Task Interdependence in Cancer Care Teams. J Oncol Pract 2017; 13:154-156. [PMID: 28118105 DOI: 10.1200/jop.2016.020156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Affiliation(s)
- Veronica Chollette
- National Cancer Institute, Bethesda, MD; Emory University, Atlanta, GA; and University of California San Francisco, San Francisco, CA
| | - Derrick D Beasley
- National Cancer Institute, Bethesda, MD; Emory University, Atlanta, GA; and University of California San Francisco, San Francisco, CA
| | - Ekland Abdiwahab
- National Cancer Institute, Bethesda, MD; Emory University, Atlanta, GA; and University of California San Francisco, San Francisco, CA
| | - Stephen Taplin
- National Cancer Institute, Bethesda, MD; Emory University, Atlanta, GA; and University of California San Francisco, San Francisco, CA
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Noël PH, Parchman ML, Finley EP, Wang CP, Bollinger M, Espinoza SE, Hazuda HP. Primary care-public health linkages: Older primary care patients with prediabetes & type 2 diabetes encouraged to attend community-based senior centers. Prev Med Rep 2016; 4:283-8. [PMID: 27462529 PMCID: PMC4950171 DOI: 10.1016/j.pmedr.2016.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/15/2016] [Accepted: 06/27/2016] [Indexed: 11/23/2022] Open
Abstract
The Institute of Medicine (IOM) suggests that primary care-public health integration can improve health outcomes for vulnerable patients, but the extent to which formal linkages may enhance patients' use of community resources, or the factors that may influence providers to encourage their patients to use these resources, remain unclear. We conducted baseline assessments in 2014-2015 with 149 older adults with prediabetes or diabetes who had recently joined three senior centers linked to a network of primary care clinics in San Antonio, Texas. In addition to collecting sociodemographic and clinical characteristics, we asked members to identify their source of primary care and whether a health care provider had encouraged them to go to the senior center. We also asked members why they had joined the senior centers and which programs interested them the most. Members' source of primary care was not associated with being encouraged to attend the senior centers by a health care professional. Multivariable analysis indicated that participants with total annual household incomes of $20,000 or less [OR = 2.78; 95% CI = (1.05, 7.14)] and those reporting 12 years of education or less [OR = 3.57; 95% CI = (1.11, 11.11)] were significantly more likely to report being encouraged to attend the senior center by a health care provider. Providers who are aware of community-based resources to support patient self-management may be just as likely to encourage their socioeconomically vulnerable patients with prediabetes or diabetes to use them as providers who have a more formal partnership with the senior centers.
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Affiliation(s)
- Polly H. Noël
- UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, United States
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, United States
| | - Michael L. Parchman
- MacColl Center for Healthcare Innovation, Group Health Research Institute, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, United States
| | - Erin P. Finley
- UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, United States
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, United States
| | - Chen-Pin Wang
- UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, United States
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, United States
| | - Mary Bollinger
- UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, United States
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, United States
| | - Sara E. Espinoza
- UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, United States
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, United States
| | - Helen P. Hazuda
- UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, United States
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Barnett ML, Mehrotra A, Frolkis JP, Spinks M, Steiger C, Hehir B, Greenberg JO, Singh H. Implementation Science Workshop: Implementation of an Electronic Referral System in a Large Academic Medical Center. J Gen Intern Med 2016; 31:343-52. [PMID: 26556594 PMCID: PMC4762816 DOI: 10.1007/s11606-015-3516-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Michael L Barnett
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Health Care Policy, Harvard Medical School, 180A Longwood Ave., Boston, MA, 02115, USA.
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, 180A Longwood Ave., Boston, MA, 02115, USA
| | - Joseph P Frolkis
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Casey Steiger
- Brigham and Women's Physicians Organization, Boston, MA, USA
| | - Brandon Hehir
- Brigham and Women's Physicians Organization, Boston, MA, USA
| | - Jeffrey O Greenberg
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Brigham and Women's Physicians Organization, Boston, MA, USA
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
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Hysong SJ, Thomas CL, Spitzmüller C, Amspoker AB, Woodard L, Modi V, Naik AD. Linking clinician interaction and coordination to clinical performance in Patient-Aligned Care Teams. Implement Sci 2016; 11:7. [PMID: 26772972 PMCID: PMC4714534 DOI: 10.1186/s13012-015-0368-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 12/31/2015] [Indexed: 11/30/2022] Open
Abstract
Background Team coordination within clinical care settings is a critical component of effective patient care. Less is known about the extent, effectiveness, and impact of coordination activities among professionals within VA Patient-Aligned Care Teams (PACTs). This study will address these gaps by describing the specific, fundamental tasks and practices involved in PACT coordination, their impact on performance measures, and the role of coordination task complexity. Methods/design First, we will use a web-based survey of coordination practices among 1600 PACTs in the national VHA. Survey findings will characterize PACT coordination practices and assess their association with clinical performance measures. Functional job analysis, using 6–8 subject matter experts who are 3rd and 4th year residents in VA Primary Care rotations, will be utilized to identify the tasks involved in completing clinical performance measures to standard. From this, expert ratings of coordination complexity will be used to determine the level of coordinative complexity required for each of the clinical performance measures drawn from the VA External Peer Review Program (EPRP). For objective 3, data collected from the first two methods will evaluate the effect of clinical complexity on the relationships between measures of PACT coordination and their ratings on the clinical performance measures. Discussion Results from this study will support successful implementation of coordinated team-based work in clinical settings by providing knowledge regarding which aspects of care require the most complex levels of coordination and how specific coordination practices impact clinical performance. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0368-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sylvia J Hysong
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. .,Department of Medicine, Health Services Research Section, Baylor College of Medicine, Houston, TX, USA.
| | - Candice L Thomas
- Department of Psychology, University of Houston, Houston, TX, USA.
| | | | - Amber B Amspoker
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. .,Department of Medicine, Health Services Research Section, Baylor College of Medicine, Houston, TX, USA.
| | - LeChauncy Woodard
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. .,Department of Medicine, Health Services Research Section, Baylor College of Medicine, Houston, TX, USA.
| | - Varsha Modi
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. .,Department of Medicine, Health Services Research Section, Baylor College of Medicine, Houston, TX, USA.
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. .,Department of Medicine, Health Services Research Section, Baylor College of Medicine, Houston, TX, USA.
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Hysong SJ, Che X, Weaver SJ, Petersen LA. Study protocol: identifying and delivering point-of-care information to improve care coordination. Implement Sci 2015; 10:145. [PMID: 26482787 PMCID: PMC4613788 DOI: 10.1186/s13012-015-0335-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/07/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The need for deliberately coordinated care is noted by many national-level organizations. The Department of Veterans Affairs (VA) recently transitioned primary care clinics nationwide into Patient Aligned Care Teams (PACTs) to provide more accessible, coordinated, comprehensive, and patient-centered care. To better serve this purpose, PACTs must be able to successfully sequence and route interdependent tasks to appropriate team members while also maintaining collective situational awareness (coordination). Although conceptual frameworks of care coordination exist, few explicitly articulate core behavioral markers of coordination or the related information needs of team members attempting to synchronize complex care processes across time for a shared patient population. Given this gap, we partnered with a group of frontline primary care personnel at ambulatory care sites to identify the specific information needs of PACT members that will enable them to coordinate their efforts to provide effective, coordinated care. The study has three objectives: (1) development of measurable, prioritized point-of-care criteria for effective PACT coordination; (2) identifying the specific information needed at the point of care to optimize coordination; and (3) assessing the effect of adopting the aforementioned coordination standards on PACT clinicians' coordination behaviors. METHODS/DESIGN The study consists of three phases. In phase 1, we will employ the Productivity Measurement and Enhancement System (ProMES), a structured approach to performance measure creation from industrial/organizational psychology, to develop coordination measures with a design team of 6-10 primary care personnel; in phase 2, we will conduct focus groups with the phase 1 design team to identify point-of-care information needs. Phase 3 is a two-arm field experiment (n PACT = 28/arm); intervention arm PACTs will receive monthly feedback reports using the measures developed in phase 1 and attend brief monthly feedback sessions. Control arm PACTs will receive no intervention. PACTs will be followed prospectively for up to 1 year. DISCUSSION This project combines both action research and implementation science methods to address important gaps in the existing care coordination literature using a partnership-based research design. It will provide an evidence-based framework for care coordination by employing a structured methodology for a systematic approach to care coordination in PACT settings and identifying the information needs that produce the most successful coordination of care. TRIAL REGISTRATION ISRCTN15412521.
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Affiliation(s)
- Sylvia J Hysong
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. .,Department of Medicine-Health Services Research Section, Baylor College of Medicine, Houston, TX, USA.
| | - Xinxuan Che
- School of Psychology, Florida Institute of Technology, Melbourne, FL, USA.
| | - Sallie J Weaver
- Johns Hopkins University School of Medicine & Johns Hopkins Medicine Armstrong Institute for Patient Safety & Quality, Baltimore, MD, USA.
| | - Laura A Petersen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. .,Department of Medicine-Health Services Research Section, Baylor College of Medicine, Houston, TX, USA.
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Battaglia C, Lambert-Kerzner A, Aron DC, Sayre GG, Ho PM, Haverhals L, Stevenson L, Kirsh S, Au DH, Helfrich CD. Evaluation of E-Consults in the VHA: Provider Perspectives. Fed Pract 2015; 32:42-48. [PMID: 30766078 PMCID: PMC6363293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
As VHA expands the use of e-consults, this study suggests that they often are more timely than are face-to-face consultations.
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Affiliation(s)
- Catherine Battaglia
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Anne Lambert-Kerzner
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - David C Aron
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - George G Sayre
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - P Michael Ho
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Leah Haverhals
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Lauren Stevenson
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Susan Kirsh
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - David H Au
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
| | - Christian D Helfrich
- is a nurse scientist, is a health services researcher, is a physician, and is a health research specialist, all at VA Eastern Colorado Health Care System in Denver. is a physician and is a research health science specialist at Louis Stokes Cleveland VA Medical Center in Ohio. is a clinical consultant at the VA Office of Specialty Care Services in Washington, DC. is a research health science specialist and qualitative resources coordinator, is a physician, and is a research investigator, all at VA Puget Sound Health Care System in Seattle, Washington. Dr. Battaglia, Dr. Lambert-Kerzner, Dr. Sayre, Dr. Ho, Ms. Haverhals, Dr. Au, and Dr. Helfrich are affiliated with the VA's Seattle-Denver Center of Innovation. Dr. Battaglia, Dr. Lambert-Kerzner, and Dr. Ho have faculty appointments at the University of Colorado in Aurora. Dr. Aron is a professor at Case Western Reserve University in Cleveland, Ohio. Dr. Sayre, Dr. Au, and Dr. Helfrich have faculty appointments at the University of Washington in Seattle
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Vargas I, Mogollón-Pérez AS, De Paepe P, da Silva MRF, Unger JP, Vázquez ML. Do existing mechanisms contribute to improvements in care coordination across levels of care in health services networks? Opinions of the health personnel in Colombia and Brazil. BMC Health Serv Res 2015; 15:213. [PMID: 26022531 PMCID: PMC4447020 DOI: 10.1186/s12913-015-0882-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 05/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The fragmentation of healthcare provision has given rise to a wide range of interventions within organizations to improve coordination across levels of care, primarily in high income countries but also in some middle and low-income countries. The aim is to analyze the use of coordination mechanisms in healthcare networks and its implications for the delivery of health care. This is studied from the perspective of health personnel in two countries with different health systems, Colombia and Brazil. METHODS A qualitative, exploratory and descriptive-interpretative study was conducted, based on a case study of healthcare networks in two municipalities in each country. Individual semi-structured interviews were conducted with a three stage theoretical sample of a) health (112) and administrative (66) professionals of different care levels, and b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes. RESULTS The results show that care coordination mechanisms are poorly implemented in general. However, the results are marginally better in certain segments of the Colombian networks analyzed (ambulatory centres with primary and secondary care co-location owned by or tied to the contributory scheme insurers, and public providers of the subsidized scheme); and in the network of the state capital in Brazil. Professionals point to numerous problems in the use of existing mechanisms, such as the insufficient recording of information in referral forms, low frequency and level of participation in shared clinical sessions, low adherence to the few available clinical guidelines and the lack of or inadequate referral of patients by the patient referral centres, particularly in the Brazilian networks. The absence or limited use of care coordination mechanisms leads, according to informants, to the inadequate follow-up of patients, interruptions in care and duplication of tests. Professionals use informal strategies to try to overcome these limitations. CONCLUSIONS The results indicate not only the limited implementation of mechanisms for coordination across care levels, but also a limited use of existing mechanisms in the healthcare networks analyzed. This has a negative impact on coordination, efficiency and quality of care. Organizational changes are required in the networks and healthcare systems to address these problems.
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Affiliation(s)
- Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, 08022, Barcelona, Spain.
| | - Amparo Susana Mogollón-Pérez
- Faculty of Medicine and Health Sciences, Universidad del Rosario, Carrera 24, No. 63C -69, 11001, Bogotá, Colombia.
| | - Pierre De Paepe
- Prince Leopold Institute of Tropical Medicine, Nationalestraat, 5, 2000, Antwerpen, Belgium.
| | | | - Jean Pierre Unger
- Prince Leopold Institute of Tropical Medicine, Nationalestraat, 5, 2000, Antwerpen, Belgium.
| | - María Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, 08022, Barcelona, Spain.
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Zuchowski JL, Rose DE, Hamilton AB, Stockdale SE, Meredith LS, Yano EM, Rubenstein LV, Cordasco KM. Challenges in referral communication between VHA primary care and specialty care. J Gen Intern Med 2015; 30:305-11. [PMID: 25410884 PMCID: PMC4351287 DOI: 10.1007/s11606-014-3100-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 10/03/2014] [Accepted: 10/29/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary-specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA). OBJECTIVE The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication. DESIGN The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCP-reported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges. PARTICIPANTS 191 VHA PCPs from one regional network were surveyed (54% response rate), and 41 VHA PCPs and primary care staff were interviewed. MAIN MEASURES/APPROACH PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed. KEY RESULTS Among PCPs, ease-of-communication ratings were highest for women's health and mental health (mean score of 2.3 on a scale of 1-3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called "eConsults" as an alternative to a traditional referral. CONCLUSIONS Primary-specialty communication is a continuing challenge that varies by specialty and may be associated with the likelihood of an established connection already in place between specialty and primary care. Improvement in EMR systems is needed, with more flexibility for the communication of special requests. Building relationships between PCPs and specialists may also facilitate referral communication.
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Affiliation(s)
- Jessica L Zuchowski
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA,
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Capsule commentary on Zuchowski et al., challenges in referral communication between VHA primary care and specialty care. J Gen Intern Med 2015; 30:344. [PMID: 25533391 PMCID: PMC4351267 DOI: 10.1007/s11606-014-3146-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Skolarus TA, Hofer TP, Montgomery JS, Hafez K, Hollenbeck BK, Shelton JB, Antonio AL, Hawley ST, Sales AE. Urologist Workforce Variation Across the VHA. Fed Pract 2015; 32:18-22. [PMID: 30766048 PMCID: PMC6363476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Distribution of urologists varies significantly at the facility rather than at the regional level, according to a large-scale study, but regional approaches, e-consults, and telemedicine may mitigate veteran access issues.
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Affiliation(s)
- Ted A Skolarus
- and are all investigators at the HSR&D Center for Clinical Management Research in the VA Ann Arbor Health Care System in Michigan. and Dr. Skolarus are all staff urologists in the Urology Section, VA Ann Arbor Health Care System and along with are members of the Department of Urology, University of Michigan. Dr. Hofer and Dr. Hawley are in the Department of Internal Medicine, University of Michigan. and are both at the VA Greater Los Angeles Healthcare System and University of California, Los Angeles. Dr. Sales is also in the Department of Systems Leadership and Effectiveness Science at the School of Nursing, University of Michigan
| | - Timothy P Hofer
- and are all investigators at the HSR&D Center for Clinical Management Research in the VA Ann Arbor Health Care System in Michigan. and Dr. Skolarus are all staff urologists in the Urology Section, VA Ann Arbor Health Care System and along with are members of the Department of Urology, University of Michigan. Dr. Hofer and Dr. Hawley are in the Department of Internal Medicine, University of Michigan. and are both at the VA Greater Los Angeles Healthcare System and University of California, Los Angeles. Dr. Sales is also in the Department of Systems Leadership and Effectiveness Science at the School of Nursing, University of Michigan
| | - Jeffrey S Montgomery
- and are all investigators at the HSR&D Center for Clinical Management Research in the VA Ann Arbor Health Care System in Michigan. and Dr. Skolarus are all staff urologists in the Urology Section, VA Ann Arbor Health Care System and along with are members of the Department of Urology, University of Michigan. Dr. Hofer and Dr. Hawley are in the Department of Internal Medicine, University of Michigan. and are both at the VA Greater Los Angeles Healthcare System and University of California, Los Angeles. Dr. Sales is also in the Department of Systems Leadership and Effectiveness Science at the School of Nursing, University of Michigan
| | - Khaled Hafez
- and are all investigators at the HSR&D Center for Clinical Management Research in the VA Ann Arbor Health Care System in Michigan. and Dr. Skolarus are all staff urologists in the Urology Section, VA Ann Arbor Health Care System and along with are members of the Department of Urology, University of Michigan. Dr. Hofer and Dr. Hawley are in the Department of Internal Medicine, University of Michigan. and are both at the VA Greater Los Angeles Healthcare System and University of California, Los Angeles. Dr. Sales is also in the Department of Systems Leadership and Effectiveness Science at the School of Nursing, University of Michigan
| | - Brent K Hollenbeck
- and are all investigators at the HSR&D Center for Clinical Management Research in the VA Ann Arbor Health Care System in Michigan. and Dr. Skolarus are all staff urologists in the Urology Section, VA Ann Arbor Health Care System and along with are members of the Department of Urology, University of Michigan. Dr. Hofer and Dr. Hawley are in the Department of Internal Medicine, University of Michigan. and are both at the VA Greater Los Angeles Healthcare System and University of California, Los Angeles. Dr. Sales is also in the Department of Systems Leadership and Effectiveness Science at the School of Nursing, University of Michigan
| | - Jeremy B Shelton
- and are all investigators at the HSR&D Center for Clinical Management Research in the VA Ann Arbor Health Care System in Michigan. and Dr. Skolarus are all staff urologists in the Urology Section, VA Ann Arbor Health Care System and along with are members of the Department of Urology, University of Michigan. Dr. Hofer and Dr. Hawley are in the Department of Internal Medicine, University of Michigan. and are both at the VA Greater Los Angeles Healthcare System and University of California, Los Angeles. Dr. Sales is also in the Department of Systems Leadership and Effectiveness Science at the School of Nursing, University of Michigan
| | - Anna Liza Antonio
- and are all investigators at the HSR&D Center for Clinical Management Research in the VA Ann Arbor Health Care System in Michigan. and Dr. Skolarus are all staff urologists in the Urology Section, VA Ann Arbor Health Care System and along with are members of the Department of Urology, University of Michigan. Dr. Hofer and Dr. Hawley are in the Department of Internal Medicine, University of Michigan. and are both at the VA Greater Los Angeles Healthcare System and University of California, Los Angeles. Dr. Sales is also in the Department of Systems Leadership and Effectiveness Science at the School of Nursing, University of Michigan
| | - Sarah T Hawley
- and are all investigators at the HSR&D Center for Clinical Management Research in the VA Ann Arbor Health Care System in Michigan. and Dr. Skolarus are all staff urologists in the Urology Section, VA Ann Arbor Health Care System and along with are members of the Department of Urology, University of Michigan. Dr. Hofer and Dr. Hawley are in the Department of Internal Medicine, University of Michigan. and are both at the VA Greater Los Angeles Healthcare System and University of California, Los Angeles. Dr. Sales is also in the Department of Systems Leadership and Effectiveness Science at the School of Nursing, University of Michigan
| | - Anne E Sales
- and are all investigators at the HSR&D Center for Clinical Management Research in the VA Ann Arbor Health Care System in Michigan. and Dr. Skolarus are all staff urologists in the Urology Section, VA Ann Arbor Health Care System and along with are members of the Department of Urology, University of Michigan. Dr. Hofer and Dr. Hawley are in the Department of Internal Medicine, University of Michigan. and are both at the VA Greater Los Angeles Healthcare System and University of California, Los Angeles. Dr. Sales is also in the Department of Systems Leadership and Effectiveness Science at the School of Nursing, University of Michigan
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Bergman J, Ballon-Landa E, Lorenz KA, Saucedo J, Saigal CS, Bennett CJ, Litwin MS. Community-Partnered Collaboration to Build an Integrated Palliative Care Clinic. Am J Hosp Palliat Care 2014; 33:164-70. [DOI: 10.1177/1049909114555156] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: We partnered with patients, families, and palliative care clinicians to develop an integrated urology–palliative care clinic for patients with metastatic cancer. We assessed clinician satisfaction with a multidisciplinary palliative care clinic model. Methods: We conducted semi-structured interviews with 18 clinicians who practice in our integrated clinic. We analyzed transcripts using a multistage, cutting-and-sorting technique in an inductive approach based on grounded theory analysis. Finally, we administered a validated physician job satisfaction survey. Results: Clinicians found that referring a patient to palliative care in the urology clinic was feasible and appropriate. Patients were receptive to supportive care, and clinicians perceived that quality of care improved following the intervention. Conclusion: An integrated, patient-centered model for individuals with advanced urologic malignancies is feasible and well received by practitioners.
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Affiliation(s)
- Jonathan Bergman
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Eric Ballon-Landa
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- UC Irvine School of Medicine, Irvine, CA, USA
| | - Karl A. Lorenz
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Josemanuel Saucedo
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Christopher S. Saigal
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Carol J. Bennett
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Mark S. Litwin
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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Kirsh SR, Ho PM, Aron DC. Providing specialty consultant expertise to primary care: an expanding spectrum of modalities. Mayo Clin Proc 2014; 89:1416-26. [PMID: 24889514 DOI: 10.1016/j.mayocp.2014.04.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 04/11/2014] [Accepted: 04/16/2014] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Susan R Kirsh
- Office of Specialty Care, Veterans Health Administration, Washington, DC; Office of Specialty Care/VA HSR&D QUERI Evaluation Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH; Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - P Michael Ho
- Office of Specialty Care/VA HSR&D QUERI Evaluation Center, Eastern Colorado Health Care System Medical Center, Aurora, CO; Department of Medicine, School of Medicine, University of Colorado Denver, Aurora, CO
| | - David C Aron
- Office of Specialty Care/VA HSR&D QUERI Evaluation Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH; Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH; Department of Organizational Behavior, Weatherhead School of Management, Cleveland, OH.
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Hysong SJ, Knox MK, Haidet P. Examining clinical performance feedback in Patient-Aligned Care Teams. J Gen Intern Med 2014; 29 Suppl 2:S667-74. [PMID: 24715398 PMCID: PMC4070233 DOI: 10.1007/s11606-013-2707-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The move to team-based models of health care represents a fundamental shift in healthcare delivery, including major changes in the roles and relationships among clinical personnel. Audit and feedback of clinical performance has traditionally focused on the provider; however, a team-based model of care may require different approaches. OBJECTIVE Identify changes in audit and feedback of clinical performance to primary care clinical personnel resulting from implementing team-based care in their clinics. DESIGN Semi-structured interviews with primary care clinicians, their department heads, and facility leadership at 16 geographically diverse VA Medical Centers, selected purposively by their clinical performance profile. PARTICIPANTS An average of three interviewees per VA medical center, selected from physicians, nurses, and primary care and facility directors who participated in 1-hour interviews. APPROACH Interviews focused on how clinical performance information is fed back to clinicians, with particular emphasis on external peer-review program measures and changes in feedback associated with team-based care implementation. Interview transcripts were analyzed, using techniques adapted from grounded theory and content analysis. KEY RESULTS Ownership of clinical performance still rests largely with the provider, despite transitioning to team-based care. A panel-management information tool emerged as the most prominent change to clinical performance feedback dissemination, and existing feedback tools were seen as most effective when monitored by the nurse members of the team. Facilities reported few, if any, appreciable changes to the assessment of clinical performance since transitioning to team-based care. CONCLUSIONS Although new tools have been created to support higher-quality clinical performance feedback to primary care teams, such tools have not necessarily delivered feedback consistent with a team-based approach to health care. Audit and feedback of clinical performance has remained largely unchanged, despite material differences in roles and responsibilities of team members. Future research should seek to unpack the nuances of team-based audit and feedback, to better align feedback with strategic clinical goals.
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Affiliation(s)
- Sylvia J Hysong
- Michael E. DeBakey VA Medical Center, Center for Innovations in Quality Safety and Effectiveness, Houston, TX, USA,
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Dullard B, Saunders GH. Documentation of Dual Sensory Impairment in Electronic Medical Records. THE GERONTOLOGIST 2014; 56:313-7. [PMID: 24846883 PMCID: PMC7289325 DOI: 10.1093/geront/gnu032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/18/2014] [Indexed: 11/12/2022] Open
Abstract
PURPOSE OF THE STUDY To examine the documentation of sensory impairment in the electronic medical records (EMRs) of Veterans with both hearing and vision losses (dual sensory impairment [DSI]). DESIGN AND METHODS A retrospective chart review of the EMRs of 20 patients with DSI was conducted. Providers' documentation of the presence of sensory impairment, the use of assistive technology during clinical appointments, and the content of notes mentioning communication issues were extracted from each chart note in the EMR for the prior 6 years. RESULTS Primary care providers documented DSI in 50% of EMRs, vision loss alone in 40%, and hearing loss alone in 10% of EMRs. Audiologists documented vision loss in 50% of cases, whereas ophthalmologists/optometrists documented hearing loss in 15% of cases. Examination of two selected cases illustrates that care can be compromised when providers do not take note of sensory impairments during planning and provision of clinical care. IMPLICATIONS Sensory impairment is poorly documented by most providers in EMRs. This is alarming because vision and hearing affect patient-physician communication and the use of medical interventions. The results of this study raise awareness about the need to document the presence of sensory impairments and use the information when planning treatment for individuals with DSI.
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Affiliation(s)
- Brittney Dullard
- Speech, Language, and Hearing Sciences, University of Connecticut, Mansfield.
| | - Gabrielle H Saunders
- National Center for Rehabilitative Auditory Research, Portland VA Medical Center, Portland, Oregon
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Braithwaite J, Marks D, Taylor N. Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. Int J Qual Health Care 2014; 26:321-9. [DOI: 10.1093/intqhc/mzu047] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Bouamrane MM, Mair FS. A qualitative evaluation of general practitioners' views on protocol-driven eReferral in Scotland. BMC Med Inform Decis Mak 2014; 14:30. [PMID: 24712766 PMCID: PMC4101875 DOI: 10.1186/1472-6947-14-30] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Accepted: 03/14/2014] [Indexed: 11/10/2022] Open
Abstract
Background The ever increasing volume of referrals from primary care to specialist services is putting considerable pressure on resource-constrained health services while effective communication across fragmented services remains a substantial challenge. Previous studies have suggested that electronic referrals (eReferral) can bear important benefits for cross-organisational processes and patient care management. Methods We conducted 25 semi-structured interviews and 1 focus group with primary care providers to elucidate General Practitioners’ (GPs) perspectives on information management processes in the patient pathway in NHSScotland, 1 focus group with members of the Scottish Electronic Patient Record programme and one interview with a senior architect of the Scottish Care Information national eReferral System (SCI Gateway). Using Normalisation Process Theory, we performed a qualitative analysis to elucidate GPs’ perspectives on eReferral to identify the factors which they felt either facilitated or hindered referral processes. Results The majority of GPs interviewed felt that eReferral substantially streamlined communication processes, with the immediate transfer of referral documents and the availability of an electronic audit trail perceived as two substantial improvements over paper-based referrals. Most GPs felt that the SCI Gateway system was reasonably straightforward to use. Referral protocols and templates could be perceived as useful by some GPs while others considered them to be cumbersome at times. Conclusion Our study suggests that the deployment and adoption of eReferral across the NHS in Scotland has been achieved by a combination of factors: (i) a policy context – including national mandatory targets for eReferral – which all NHS health-boards were bound to operationalise through their Local Delivery Plans and also (ii) the fact that primary care doctors considered that the overall benefits brought by the deployment of eReferral throughout the patient pathway significantly outweigh any potential disbenefits.
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Affiliation(s)
- Matt-Mouley Bouamrane
- University of Aberdeen, Institute of Applied Health Sciences, Aberdeen, Scotland, UK.
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Giardina TD, King BJ, Ignaczak A, Paull DE, Hoeksema L, Mills PD, Neily J, Hemphill RR, Singh H. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health Aff (Millwood) 2013; 32:1368-75. [PMID: 23918480 PMCID: PMC3822525 DOI: 10.1377/hlthaff.2013.0130] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Delays in diagnosis and treatment are widely considered to be threats to outpatient safety. However, few studies have identified and described what factors contribute to delays that might result in patient harm in the outpatient setting. We analyzed 111 root cause analysis reports that investigated such delays and were submitted to the Veterans Affairs National Center for Patient Safety in the period 2005-12. The most common contributing factors noted in the reports included coordination problems resulting from inadequate follow-up planning, delayed scheduling for unspecified reasons, inadequate tracking of test results, and the absence of a system to track patients in need of short-term follow-up. Other contributing factors were team-level decision-making problems resulting from miscommunication of urgency between providers and providers' lack of awareness of or knowledge about a patient's situation; and communication failures among providers, patients, and other health care team members. Our findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems will require enhancements. At the same time, policy initiatives should support programs to implement, and perhaps reward the use of, more rigorous interprofessional teamwork principles to improve outpatient communication and coordination.
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Affiliation(s)
- Traber Davis Giardina
- Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| | - Beth J. King
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Aartee Ignaczak
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Douglas E. Paull
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Laura Hoeksema
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Peter D. Mills
- Field Office, VA National Center for Patient Safety, White River Junction, Vermont, USA
- Adjunct Associate Professor of Psychiatry, The Geisel School of Medicine at Dartmouth
| | - Julia Neily
- Field Office, VA National Center for Patient Safety, White River Junction, Vermont, USA
| | - Robin R. Hemphill
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Hardeep Singh
- Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas USA
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Benzer JK, Beehler S, Cramer IE, Mohr DC, Charns MP, Burgess JF. Between and within-site variation in qualitative implementation research. Implement Sci 2013; 8:4. [PMID: 23286552 PMCID: PMC3598511 DOI: 10.1186/1748-5908-8-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 12/11/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Multisite qualitative studies are challenging in part because decisions regarding within-site and between-site sampling must be made to reduce the complexity of data collection, but these decisions may have serious implications for analyses. There is not yet consensus on how to account for within-site and between-site variations in qualitative perceptions of the organizational context of interventions. The purpose of this study was to analyze variation in perceptions among key informants in order to demonstrate the importance of broad sampling for identifying both within-site and between-site implementation themes. METHODS Case studies of four sites were compared to identify differences in how Department of Veterans Affairs (VA) medical centers implemented a Primary Care/Mental Health Integration (PC/MHI) intervention. Qualitative analyses focused on between-profession variation in reported referral and implementation processes within and between sites. RESULTS Key informants identified co-location, the consultation-liaison service, space, access, and referral processes as important topics. Within-site themes revealed the importance of coordination, communication, and collaboration for implementing PC/MHI. The between-site theme indicated that the preexisting structure of mental healthcare influenced how PC/MHI was implemented at each site and that collaboration among both leaders and providers was critical to overcoming structural barriers. CONCLUSIONS Within- and between-site variation in perceptions among key informants within different professions revealed barriers and facilitators to the implementation not available from a single source. Examples provide insight into implementation barriers for PC/MHI. Multisite implementation studies may benefit from intentionally eliciting and analyzing variation within and between sites. Suggestions for implementation research design are presented.
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Affiliation(s)
- Justin K Benzer
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
| | - Sarah Beehler
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
| | - Irene E Cramer
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
| | - David C Mohr
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
| | - Martin P Charns
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
| | - James F Burgess
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
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Hysong SJ, Simpson K, Pietz K, SoRelle R, Broussard Smitham K, Petersen LA. Financial incentives and physician commitment to guideline-recommended hypertension management. THE AMERICAN JOURNAL OF MANAGED CARE 2012; 18:e378-e391. [PMID: 23145846 PMCID: PMC4169298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To examine the impact of financial incentives on physician goal commitment to guideline-recommended hypertension care. STUDY DESIGN Clinic-level cluster-randomized trial with 4 arms: individual, group, or combined incentives, and control. METHODS A total of 83 full-time primary care physicians at 12 Veterans Affairs medical centers completed web-based surveys measuring their goal commitment to guideline-recommended hypertension care every 4 months and telephone interviews at months 8 and 16. Intervention arm participants received performance-based incentives every 4 months for 5 periods. All participants received guideline education at baseline and audit and feedback every 4 months. RESULTS Physician goal commitment did not vary over time or across arms. Participants reported patient nonadherence was a perceived barrier and consistent follow-up was a perceived facilitator to successful hypertension care, suggesting that providers may perceive hypertension management as more of a patient responsibility (external locus of control). CONCLUSIONS Financial incentives may constitute an insufficiently strong intervention to influence goal commitment when providers attribute performance to external forces beyond their control.
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