Towards successful coordination of electronic health record based-referrals: a qualitative analysis
Towards successful coordination of electronic health record based-referrals: a qualitative analysis
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DOI：
10.1186/1748-5908-6-84
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发表时间：
2011-07-27
影响因子：
7.2
通讯作者：
Singh, Hardeep
中科院分区：
文献类型：
--
作者：
Hysong, Sylvia J.;Esquivel, Adol;Singh, Hardeep
背景：成功的专科转诊需要初级保健提供者(PCP)、专科专科医生和患者之间的大量协调和互动沟通，这在门诊环境中可能是具有挑战性的。即使电子健康记录(EHR)为转诊提供了便利(即电子转诊)，也可能会出现患者随访失误的情况。尽管有令人信服的理由说明为什么应改进转介协调，但对于复杂的转介协调过程中的哪些要素应加以改进却知之甚少。利用Okhuysen和Bechky的协调框架，本文旨在了解在综合医疗系统中改善基于电子病历的转诊的沟通和协调的障碍、促进者和建议。方法：我们进行了一项定性研究，以了解综合医疗系统中与电子转诊相关的协调故障，并考察了影响专科护理及时接受的工作系统因素。我们对退伍军人事务部(VA)两个三级医疗中心的7名主题专家和6个焦点小组进行了访谈，共30名初级医生和亚专家。使用扎根理论和内容分析的方法，我们确定了影响转诊过程的组织主题。结果：出现了四个主题：缺乏制度性转诊政策，某些转诊程序缺乏标准化，角色和职责不明确，以及资源不足，无法有效地适应和回应转诊请求。初级保健医生和次级专家的沟通方式和转介过程的个人心理模式存在显著差异，这可能妨碍建立共同的心理模式，以促进协调和成功完成转介。值得注意的是，与电子健康记录相关的障碍很少被报道。结论：尽管电子推荐促进了初级保健医生和专家之间的信息传递，但电子推荐仍然容易出现协调障碍。在实施电子健康记录之前，必须制定明确的转介政策、明确界定的关键人员的角色和责任、标准化的程序和通信协议以及充足的人力资源，以促进转介。
Background: Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may be challenging in the outpatient setting. Even when referrals are facilitated by electronic health records (EHRs) (i.e., e-referrals), lapses in patient follow-up might occur. Although compelling reasons exist why referral coordination should be improved, little is known about which elements of the complex referral coordination process should be targeted for improvement. Using Okhuysen & Bechky's coordination framework, this paper aims to understand the barriers, facilitators, and suggestions for improving communication and coordination of EHR-based referrals in an integrated healthcare system.Methods: We conducted a qualitative study to understand coordination breakdowns related to e-referrals in an integrated healthcare system and examined work-system factors that affect the timely receipt of subspecialty care. We conducted interviews with seven subject matter experts and six focus groups with a total of 30 PCPs and subspecialists at two tertiary care Department of Veterans Affairs (VA) medical centers. Using techniques from grounded theory and content analysis, we identified organizational themes that affected the referral process.Results: Four themes emerged: lack of an institutional referral policy, lack of standardization in certain referral procedures, ambiguity in roles and responsibilities, and inadequate resources to adapt and respond to referral requests effectively. Marked differences in PCPs' and subspecialists' communication styles and individual mental models of the referral processes likely precluded the development of a shared mental model to facilitate coordination and successful referral completion. Notably, very few barriers related to the EHR were reported.Conclusions: Despite facilitating information transfer between PCPs and subspecialists, e-referrals remain prone to coordination breakdowns. Clear referral policies, well-defined roles and responsibilities for key personnel, standardized procedures and communication protocols, and adequate human resources must be in place before implementing an EHR to facilitate referrals.