Applying Relational Coordination to Implement a Pulmonary E-consult Intervention

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Introduction: This is the second submission of a VA HSR&D CDA proposal for Seppo Rinne, MD PhD. Dr. Rinne is a practicing VA Pulmonologist, Clinical Informaticist, and a Core Investigator in the HSR&D Center for Healthcare Organization and Implementation Research (CHOIR). This proposal incorporates extensive revisions to address prior reviewer comments, which has led to a refined research focus and a rigorous career development plan. Since the first CDA submission, Dr. Rinne transferred to a new VA research environment that is closely aligned with his career goals, updated his mentoring and advising team to support these new goals, and established strong working relationships with key operational partners. The current proposal builds on Dr. Rinne’s previous training experiences and preliminary research to improve multidisciplinary coordination of pulmonary care by developing and implementing a theoretically-based informatics intervention. Background: Access to specialty care is often insufficient to meet demand. To improve timeliness and efficiency of specialty care, VA implemented electronic consultations (e-consults), which allow asynchronous provider-provider coordination through the electronic health record. However, limited research has considered potential unintended consequences of e-consults on patients’ and providers’ relationships and their quality of communication. Relational Coordination (RC) Theory provides insight that can address these gaps in knowledge and inform the design and implementation of e-consult interventions. Objective: To combine RC Theory with an established implementation model to guide the following Aims: Aim 1: Explore patient, PCP, and pulmonologist perspectives of e-consults and relationships. Aim 2: Develop consensus on essential components of pulmonary e-consult communication. Aim 3: Design and implement a pulmonary E-consult-First intervention. Methods: Aim 1 will use semi-structured interviews to explore perspectives on how e-consults impact interpersonal relationships and how patients and providers develop high quality relationships in the context of frequent e-consult use. Aim 2 will use a multi-step process with Delphi panels and Veteran focus groups to develop consensus on essential components of pulmonary e-consult communication. Aim 3 will: (A) apply a novel implementation strategy using social network analysis to identify influential individuals who can act as change agents; (B) work with these individuals and other local stakeholders to adapt information from Aims 1 and 2 to develop an e-consult intervention; and (C) evaluate the effect of the intervention and implementation strategy by conducting interviews to assess implementation outcomes, interrupted time-series analysis to examine wait times, and patient and provider surveys on satisfaction and the quality of coordination. Expected results: The proposed research will identify evidence-based practices to build and maintain patient and provider relationships that support e-consult use and establish new communication norms. These findings will inform the design and implementation of a successful e-consult intervention grounded in RC Theory that will be highly transferrable and adaptable to local contexts. Conclusions: Informatics interventions that consider humanistic elements of relationships and communication will lead to better healthcare delivery. Research on pulmonary e-consults will act as a model to improve quality and efficiency across specialty care. Therefore, the research outlined in this proposal is highly relevant to VA priorities of improving the timeliness of care, modernizing systems, and focusing resources more efficiently. Dr. Rinne is supported by a robust mentoring team, strong operational partners, and an outstanding research environment. The research and training objective described in this CDA proposal will provide him with the necessary knowledge and skills to become a successful and independent VA investigator focused on improving multidisciplinary coordination through novel, informatics-based interventions.