Challenges in Referral Communication Between VHA Primary Care and Specialty Care

Abstract

BACKGROUND:Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary-specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA). OBJECTIVE: The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication. DESIGN:The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCPreported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges. PARTICIPANTS: 191 VHA PCPs from one regional network were surveyed (54 % response rate), and 41 VHA PCPs and primary care staff were interviewed. MAIN MEASURES/APPROACH: PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed. KEY RESULTS: Among PCPs, ease-of-communication ratings were highest for women's health and mental health (mean score of 2.3 on a scale of 1-3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called "eConsults" as an alternative to a traditional referral.CONCLUSIONS: Primary-specialty communication is a continuing challenge that varies by specialty and may be associated with the likelihood of an established connection already in place between specialty and primary care. Improvement in EMR systems is needed, with more flexibility for the communication of special requests. Building relationships between PCPs and specialists may also facilitate referral communication.

Brazilian Specialists’ Perspectives on the Patient Referral Process

“…In an earlier study, Poon et al [27] found that primary care physicians reviewed 1000 individual diagnostic studies weekly and spent an average of 74 min per day doing results reviews. Technology, such as electronic medical records (EMRs) is a strategy for information and knowledge management [10]. Technology, however, has its own challenges and workload demands [28].…”

“…One recent mixed methods study within the Veteran Hospital Administration (VHA) found that a shared EMR was no panacea for an effective referral process. Effective referral communications were influenced by opportunities for primary care-specialist physicians to engage in other forms of dialogue and more personal interactions (e.g., telephone, face-to-face) that promoted collaborative relationships and trust among physicians [10]. …”

“…National trends, however, are showing that referrals to specialty services and use of these more expensive services are not decreasing. One rationale is lack of effective communications between primary care physicians and specialists, resulting in unnecessary referrals for specialty care [10]. …”

Teleconsultation Using Mobile Phones for Diagnosis and Acute Care of Burn Injuries Among Emergency Physicians: Mixed-Methods Study (Preprint)

“…These messages would often be of a friendly nature including phrases such as "dear Dr" or "kind regards". This highlights the fact that a consultation is not merely an exchange of information but also a collaboration that requires personal communication [60].…”

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

“…In interviews, primary care physicians have praised the potential of e-Consults as a fast and easy way to increase efficiency of provider communication (Zuchowski et al, 2015). Early survey results show very high rates of satisfaction among primary care physicians (93 percent satisfied) and patients, with lower satisfaction rates for specialists (53 per cent satisfied).…”