Paper persistence, workarounds, and communication breakdowns in computerized consultation management

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Abstract

Objective

The consultation request process between primary care and specialty services often contains paper-based components that may be inefficient and difficult to track. Other barriers may include workarounds and communication breakdowns with the potential to adversely impact delivery of quality medical care. We investigated current challenges to the electronic outpatient consult management process in the United States Veterans Health Administration (VHA).

Design

We conducted ethnographic observation and semi-structured interviews in nine different specialty clinics and three primary care clinics in a large, tertiary Veterans Affairs Medical Center (VAMC). We also performed a national-level query of ‘electronic error and enhancement requests’ (E3Rs) related to the consult package in the VA's electronic health record (EHR) submitted over a 5-year period (2005–2009).

Measurements

Two researchers recorded the observable interactions and interview responses of 16 healthcare workers related to their work with consultations. Two separate coding schemes were applied to both the observational and the interview data. E3Rs from the national query were reviewed and categorized based on the nature of the enhancement requests.

Results

We identified several examples of paper persistence, as well as workarounds, communication breakdowns, and redundancies in computerized consult management. An analysis of enhancement requests for the consults also revealed three broad needs related to reporting, configuration or customization, and user interface enhancements.

Conclusion

Understanding these challenges to the current consult management process is important to help design enhanced informatics tools integrated into workflow to support coordination of care and tracking of consults requests.

Highlights

► We investigated challenges to using computerized consults in the Veterans Health Administration. ► We identified cases of paper persistence, workarounds, and communication breakdowns. ► Understanding these challenges is important to design enhanced informatics tools.

Introduction

Even with the use of a computerized consultation package in an electronic health record (EHR), the consult request process often contains paper-based components that may be inefficient and are difficult to track, with the potential to adversely impact delivery of quality medical care. Conversely, some of these manual components may offer efficiencies and other advantages over corresponding electronic workflows and disclose potential limitations of the electronic processes [1], [2], [3]. Further, barriers to effective consultations have been reported in previous literature. For example, Conley et al. noted that more than one in four consultations did not contain a clear clinical question, illustrating poor communication between clinicians, in their study of medical consultations in two medical teaching units [4]. Similarly, Gandhi et al. found several “communication breakdowns” in consultation management, including timeliness of information from either the primary care provider (PCP) or specialist, lack of clarity of note content from the PCP, and the specialist not having enough information in the initial consult request [5]. Barriers to effective consultations such as these may result in delays in patient care and subsequently impact the quality of medical care.

Using a multi-method approach, we sought to develop an understanding of the current challenges to the outpatient consult management process in the United States Veterans Health Administration (VHA) from three distinct perspectives: specialty clinics, primary care clinics, and informatics or (information technology) IT support. For the specialty and primary care clinic perspectives, we observed and interviewed healthcare workers involved in consultation management in a large tertiary VA Medical Center (VAMC). For the IT support perspective, we performed a nationwide query of enhancement requests submitted by clinical application coordinators (CACs) and other support staff related to the consultation package in the VA's EHR, known as the Computerized Patient Record System (CPRS). CPRS is an integrated program with multiple software packages designed to allow clinicians to perform documentation and order medications, laboratory tests, consultations, etc. A detailed description of CPRS is available in other articles [6], [7]. An additional objective of this study was to substantiate findings from our previous work on paper persistence with an EHR [2] by focusing on paper use with the consult package, a specific EHR application.

To help frame our study, we used the sociotechnical systems framework, which has also been useful for framing other recent medical informatics work [8], [9]. The sociotechnical framework distinguishes three integrated parts of a work system: social, technical, and environmental subsystems (including internal and external) [10], [11]. In the context of consult management in the VAMC, the social subsystem is comprised of the primary care provider, who initiates the consult request; the specialist who performs the consult; the clinical staff who help manage incoming consults; the administrators who oversee consult management; and the patients being referred. The technical subsystem includes CPRS and the consult management package, printed materials, as well as any technological tools used for consult management (e.g., electronic spreadsheets and scheduling software). Psychosocial and physical components comprise the internal environment [11]. The external environmental includes any external influences on the consult management process such as national VA performance measurement, local culture and context. Ideally, the social and technical subsystems, as well as the internal environment, are balanced, or ‘jointly optimized’ [10], to meet the demands of the external environment. Finally, the work practices in the sociotechnical system are networks comprised of elements from each of the subsystems. We frame our findings against this sociotechnical framework and describe how they can inform the design of an improved consult management clinical information system.

Section snippets

Methods

For this IRB-approved multi-method study, two of the authors (JS, PB) conducted ethnographic observation and semi-structured interviews of 16 healthcare workers in nine different specialty clinics in the VAMC. Ethnographic field observation is an approach that allows study of a complex system, such as in situ use of an electronic health record, from its sociotechnical influences in the larger organization down through problems at the computer interface level [12]. Ethnographic observation is an

Results

Findings from applying the first coding scheme are reported under ‘Paper persistence’. Results from the second coding pass are reported under ‘Workarounds’, ‘Communication breakdowns’, and ‘Redundancies’. Finally, the analysis of the E3Rs is included under ‘Enhancement requests to the consult package’.

Discussion

Paper persistence, workarounds, and communication breakdowns were revealed in our analysis of the computerized consult process with the VA's EHR. Also, an analysis of enhancement requests to the consult package revealed three broad needs for improvement: consult reporting, configuration or customization, and its user interface. Understanding these challenges to the current consult management process are important to help design enhanced informatics tools integrated into workflow to support

Conclusion

We identified several categories of paper persistence, as well as workarounds, communication breakdowns, and redundancies in the consult management process. An analysis of enhancement requests for the consults in the VA's EHR also revealed three broad needs related to reporting, configuration or customization, and user interface enhancements. Our findings were organized using the sociotechnical systems framework. For example, understanding why clinicians rely on paper-based workarounds (poor

Author contributions

Jason Saleem led the conception and design of the study, acquisition of data, analysis, and interpretation of data. Jason Saleem also led the drafting the article and approved the final version. Alissa Russ participated in the conception and design of the study and interpretation of the data. Alissa Russ also critically revised the manuscript for important intellectual content and approved the final version. Adam Neddo participated in the analysis and interpretation of the data, as well as

Competing interests

The authors report no conflicts of interest.

Acknowledgements

Dr. Saleem and his research are supported by a VA Health Services Research & Development (HSR&D) Career Development Award (CDA 09-024-1). This work is supported in part by a VA Greenfield Innovation Award, ‘Consult Management Integration Interface’ (program ID#198), as well as the VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), HSR&D Center grant #HFP 04-148. Dr. Saleem is a research investigator at the Richard L. Roudebush VA Medical Center in Indianapolis, IN,

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