By Melinda Young
An impediment to care transition occurs when primary care providers (PCPs) refer patients to specialty consultants and do not send enough information, the authors of a recent study found.1
Referring patients to specialists requires a lot of documentation. Studies show that these types of transitions often have information breakdowns, says April Savoy, PhD, study co-author and a research scientist for the Center for Health Services Research at Regenstrief Institute in Indianapolis. Savoy also is an assistant professor of computer information and graphic technology at Purdue School of Engineering and Technology.
Breakdowns include the referring physician not receiving information, such as visit notes or recommendations, from the consultant. “That’s the back end that’s closing the loop,” Savoy says.
Care coordination takes more than one person to be performed effectively. The best results could occur when a care team is involved in working with patients and communicating their medical needs from one office to another.
Everyone from case managers to nurses to physicians and other staff could be included in the process of designing communication solutions as well, Savoy notes. “We include everyone in that process because everyone has a different perspective,” she says.
When specialists do not provide information and coordination after receiving the referral, then the primary care provider does not receive an answer that could be critical to treating the patient.
“With healthcare being coordinated across institutions, we realized that institutional care organizations are even more plagued with challenges because of limited overlaps with health information technology,” Savoy says.
The referral process breaks down whenever there are care delays, unnecessary repeated testing, or when information is not transferred to or from referring physicians or consultants. “That creates delays in care, patient safety risk, and both patient and clinician frustration,” Savoy explains.
Information gaps occur in both directions. “You have been referred by a PCP to a specialist for colorectal cancer, and the specialist needs background information and needs to know testing [results] and your family history — and they don’t have it,” Savoy says.
This can delay care or result in unnecessary duplicated tests. “Now you have to come back and do it all over again, or you have to wait. That creates a lot of anxiety,” Savoy says. “Cross-institutional care is exacerbating it.”
Access Is an Issue
PCPs and specialists may not have access to the same electronic medical records (EMRs). They may have to rely on information the patient tells them or brings to the visit. “That increases burdens on patients,” Savoy says. Healthcare providers need to assess organizational policies that create barriers to more efficient care transitions.
Electronic communication technology is available. The problem is accessing it. “There are design and implementation issues,” Savoy explains.
In implementing communication technology, Savoy suggests asking these questions:
- Who is considered?
- Did you talk to people performing the work?
- Did you call people multiple times to design a solution?
- Is organizational policy support design needed?
- How many times is a fax sent to another physician, but it never goes through?
“Before this study, we had not captured the measures that are not easily quantifiable,” Savoy notes. “We captured physicians talking about 100-page text they had to go through or that they didn’t have before a patient encounter.”
Looking at the human factors from an engineering perspective, Savoy and colleagues found that the problems related to communication breakdowns involved data transfers, such as a fax machine receiving a document that has to be put into the EMR. “Those are extra steps not measured in the workflow,” Savoy says. “We talked about recommendations and low-hanging fruit. One big issue physicians repeatedly discuss is they don’t have the contact information for the referring physician.”
Overreliance on Old Tech
One could argue there is an overreliance on fax machines in healthcare settings. “As a computer scientist and engineer, it broke my heart when I found out how much this practice is relying on the fax machine,” Savoy laments. “I thought they were a thing of the past.”
Indeed, data hackers in 2024 are not going after information sent through fax machines. “But that’s not a reason we should have them,” Savoy argues. “The thing about electronic health records and health information systems is we can do it faster — but if you don’t have access, you have nothing.”
Even when physicians can access a health system’s EMR system, they have to log into another system and follow other steps. “Physicians are not motivated to do this,” Savoy explains. “When they do it, they have to take more time — and when they take more time and get the [records], it may not have the information they need.”
Faxed records also are time-consuming to read. “A physician has to bumble through 100 pages of information to find what they need,” she says.
Physicians cannot search faxed pages, even if these are scanned into the computer. Although physicians could search for specific items in an EMR, they often fail to find what they are looking for. “It’s like the Twilight Zone there,” Savoy says.
Workarounds, such as asking patients to bring their medical records or access them on their phones to show physicians, also are far from ideal.
“We want patients to focus on their health. Patients are not human thumb drives, and we don’t want physicians to overcompensate for issues of technology,” Savoy says.
There are ways healthcare professionals can improve communication. For instance, many offices lack updated contact information of providers to which referrals are sent or received. “Why isn’t someone taking time to update the physician directory?” Savoy asks. “That alone would save a lot of misattempts or having no information at all.”
Organizations could assess their overreliance on fax machines. Unlike emails, fax machine information can take a while to download and print, or it may never arrive. “They may have to take time to go find the fax,” Savoy adds.
A possible solution is for the fax receiver to give the sender confirmation of when the message is received or to let them know when the message failed to arrive so they can try again.
Ways to Improve Communication
Savoy gives these suggestions for improving communication between healthcare professionals:
• Design solutions with input from those on the front lines. “Design solutions with the people who are doing the work, and then create policies and implementation strategies to support the designs,” Savoy suggests.
For instance, if those on the front lines say they need an additional person on staff to support the changes, then the organization could make this happen.
• Create auto-notifications for messages received or needed. The goal would be to design a notification that would show whether a message had been sent or if it is needed, Savoy says. The notification could include an option for turning it on when needed, and it may be different from the other types of notifications that physicians receive.
• Increase user control to address barriers. Technology solutions to communication should include ways for people to initiate searches, request tags, and use chat functions to find answers to specific questions. For example, if a case manager or clinician sends a provider a patient’s recent medical history, there could be a chat function that allows the receiver to ask a follow-up question.
“Those things are not readily available, although we know they are possible,” Savoy says. “When information is sent cross-institution, they don’t share those tag options.”
• Access emerging technologies involving health information exchange. “The next step is if we can get a participatory design [and get] patients, caregivers, and physicians in a room to say how we can better design this or better implement not only the technology but also the policies supporting the implementation of design,” Savoy says.
This step could help with the user experience of new communication technology. “We can have the best design for a health information exchange, but if policies say we can’t talk with each other, then we’re stuck in the water,” Savoy says. “It has to be designed with people using it. The policies and implementation in both internal and external environments should support that interoperability and connection across healthcare systems.”
REFERENCE
- McCormack C, Savoy A, Mathew A, et al. Characterizing barriers to closing cross-institutional referral loops: Workflow and information flow analysis. Appl Ergon 2024;Feb:115:104177. doi: 10.1016/j.apergo.2023.104177. [Epub 2023 Nov 27].
An impediment to care transition occurs when primary care providers refer patients to specialty consultants and do not send enough information, the authors of a recent study found.
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