Presentation
Closing the cross-institutional referral loop: Consultants’ and referrers’ perceived barriers and impact on clinical care
DescriptionBackground: Cross-institutional referrals are prone to communication breakdowns, which increase patient safety risks, clinician burnout, and healthcare costs. To close these external referral loops, referring primary care physicians (PCPs) need to receive clinical information from external consultants, who evaluate or treat their patients. Although existing studies investigated the early phases of external referral loops, there is a lack of sufficient knowledge about the closing phases of these loops. This study’s objectives were to characterize consultants’ and referrers’ perceived barriers to completing external referrals, and those barriers’ implications for patient care.
Participants, Settings, and Recruitment: We recruited physicians from primary care clinics and specialized consulting clinics at academic medical centers, primarily from two healthcare networks in the Midwest with different electronic health record systems. Both provide physicians access to HIE technology, such as CareWeb and Docs4Docs. We sought to recruit at least 12 PCP referrers and 12 consultants to reach data saturation, which is typically reached with approximately 10-15 participants. We used convenience sampling for both groups, due to recruiting difficulties posed by the COVID-19 pandemic. PCPs from primary care and internal medicine were eligible for the referrer interviews. Among frequently referred specialties, consultants from neurology, gastroenterology, cardiology, and oncology were eligible. Eligible clinicians were contacted via email and phone calls.
Methods: We conducted semi-structured interviews with referrers and external consultants. Based on the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 framework, we conducted rapid qualitative analyses, determining perceived barriers and related implications. Rapid qualitative data analysis occurred with an iterative inductive approach, with codes being defined a priori from the interview guide, and revised during initial analysis to include emerging themes. We illustrated themes with respondent quotations. Two members of the team created a matrix of barriers, system factors, and quotations.
Results: Referrers were predominantly female (83%) and White (66%), with work experience ranging from 10 to 32 years. Referrers practiced internal medicine, geriatrics, or primary care. Consultants were predominantly male (58%), White (58%) or Asian (33%), with experience ranging from 11 to 46 years. Consultants practiced in gastroenterology, neurology, cardiology, or oncology. Physicians described three main barriers in external referrals: receipt of excessive and unnecessary faxed documents, missing or delayed documentation, and organizational policies regarding information privacy interfering with closing the loop. Compared to internal referrals, physicians reported increased staff burden, patient frustration, and delays in diagnosis with external referrals.
Conclusion: Physicians reported technological and organizational barriers to closing cross-institutional referral loops. These barriers illustrated the necessity of communication and information sharing for patient care coordination across institutions. Consequently, potential for HIE technological solutions for cross-institutional referrals exists, but effective designs, implementation, and adoption are essential for future success. This study provides evidence that informs future human factors engineering research to address perceived barriers and guide future HIE design or implementation.
Participants, Settings, and Recruitment: We recruited physicians from primary care clinics and specialized consulting clinics at academic medical centers, primarily from two healthcare networks in the Midwest with different electronic health record systems. Both provide physicians access to HIE technology, such as CareWeb and Docs4Docs. We sought to recruit at least 12 PCP referrers and 12 consultants to reach data saturation, which is typically reached with approximately 10-15 participants. We used convenience sampling for both groups, due to recruiting difficulties posed by the COVID-19 pandemic. PCPs from primary care and internal medicine were eligible for the referrer interviews. Among frequently referred specialties, consultants from neurology, gastroenterology, cardiology, and oncology were eligible. Eligible clinicians were contacted via email and phone calls.
Methods: We conducted semi-structured interviews with referrers and external consultants. Based on the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 framework, we conducted rapid qualitative analyses, determining perceived barriers and related implications. Rapid qualitative data analysis occurred with an iterative inductive approach, with codes being defined a priori from the interview guide, and revised during initial analysis to include emerging themes. We illustrated themes with respondent quotations. Two members of the team created a matrix of barriers, system factors, and quotations.
Results: Referrers were predominantly female (83%) and White (66%), with work experience ranging from 10 to 32 years. Referrers practiced internal medicine, geriatrics, or primary care. Consultants were predominantly male (58%), White (58%) or Asian (33%), with experience ranging from 11 to 46 years. Consultants practiced in gastroenterology, neurology, cardiology, or oncology. Physicians described three main barriers in external referrals: receipt of excessive and unnecessary faxed documents, missing or delayed documentation, and organizational policies regarding information privacy interfering with closing the loop. Compared to internal referrals, physicians reported increased staff burden, patient frustration, and delays in diagnosis with external referrals.
Conclusion: Physicians reported technological and organizational barriers to closing cross-institutional referral loops. These barriers illustrated the necessity of communication and information sharing for patient care coordination across institutions. Consequently, potential for HIE technological solutions for cross-institutional referrals exists, but effective designs, implementation, and adoption are essential for future success. This study provides evidence that informs future human factors engineering research to address perceived barriers and guide future HIE design or implementation.
Event Type
Oral Presentations
TimeMonday, March 251:30pm - 1:48pm CDT
LocationSalon A-3
Patient Safety Research and Initiatives