Purdue School of Engineering and Technology, Indiana University - Purdue University, 799, W Michigan St, Indianapolis, IN 46202, United States; Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, 1481, West Tenth St, Indianapolis, IN 46202-2884, United States; Regenstrief Institute, Inc., 1101 W 10(th) St, Indianapolis, IN 46202, United States.
Regenstrief Institute, Inc., 1101 W 10(th) St, Indianapolis, IN 46202, United States; School of Science, Indiana University Purdue University, 402 North Blackford St., LD 222, Indianapolis, IN 46202, United States.
Int J Med Inform. 2023 Dec;180:105265. doi: 10.1016/j.ijmedinf.2023.105265. Epub 2023 Oct 16.
Cross-institutional (external) referrals are prone to communication breakdowns, increasing patient safety risks, clinician burnout, and healthcare costs. To close these external referral loops, referring primary care physicians (PCPs) need to receive patient information from consultants at different healthcare institutions. Although existing studies investigated the early phases of external referral loops, we lack sufficient knowledge about the closing phases of these loops. This knowledge could allow health care institutions to improve care coordination and rates of closed referral loops by implementing socio-technical interventions for patient information exchange throughout a referral loop. Human factors engineering (HFE) provides a systematic approach to advance our understanding of barriers perceived by physicians. Using HFE, our objective was to characterize referring and consulting physicians' barriers to closing referral loops and implications for care.
This qualitative cross-sectional study included semi-structured interviews with referrers and external consultants. We used the Systems Engineering Initiative for Patient Safety 2.0 framework to conduct rapid qualitative analyses, determining perceived barriers and related implications. Main measures were consultants' and referrers' perceptions of, and experiences with, barriers to external referrals.
Six referring PCPs and 12 consultants participated from two healthcare systems and four medical specialties. Physicians perceived three main barriers in external referrals: receipt of excessive and unnecessary faxed documents, missing or delayed documentation, and organizational policies regarding information privacy interfering with closing the loop. Compared to internal referrals, physicians reported increased staff burden, patient frustration, and delays in diagnosis with external referrals. Consultants reported the ability to provide the same level of care to patients with internal or external referrals. However, consultants described communication breakdowns that prohibited confirmation of follow-up plan retrieval, initiation, or effectiveness.
Physicians reported technological and organizational barriers to closing cross-institutional referral loops. Promises of HIE technology for external referrals have not fully materialized. Among physicians and patients, retrieval and exchange of medical information increases perceived workload, burden, and frustration. These increases are not accurately captured by traditional organizational metrics. This study provides evidence that informs future human factors engineering research to address perceived barriers and guide future HIE design or implementation.
机构间（外部）转诊容易导致沟通中断，增加患者安全风险、临床医生倦怠和医疗保健成本。为了封闭这些外部转诊循环，转诊的初级保健医生（PCP）需要从不同医疗机构的顾问那里接收患者信息。尽管现有研究调查了外部转诊循环的早期阶段，但我们对这些循环的封闭阶段知之甚少。这些知识可以使医疗机构通过在整个转诊循环中实施用于患者信息交换的社会技术干预措施来改善护理协调和封闭转诊循环的比例。人为因素工程（HFE）提供了一种系统的方法来提高我们对医生感知到的障碍的理解。使用 HFE，我们的目标是描述转诊医生和外部顾问在封闭转诊循环方面的障碍以及对护理的影响。
这项定性的横断面研究包括对转诊医生和外部顾问进行半结构化访谈。我们使用患者安全系统工程倡议 2.0 框架进行快速定性分析，确定感知到的障碍和相关影响。主要措施是顾问和转诊医生对外部转诊的看法和经验，以及对外部转诊的看法和经验。
来自两个医疗系统和四个医学专业的 6 名初级保健医生和 12 名顾问参与了研究。医生们认为外部转诊有三个主要障碍：收到过多和不必要的传真文件、文档缺失或延迟，以及信息隐私的组织政策干扰了循环的封闭。与内部转诊相比，医生报告说外部转诊会增加员工负担、患者沮丧和诊断延迟。顾问报告说，他们能够为内部或外部转诊的患者提供相同水平的护理。然而，顾问们描述了沟通中断，这使得他们无法确认后续计划的检索、启动或效果。
医生们报告说，关闭机构间转诊循环存在技术和组织障碍。HIE 技术在外部转诊中的承诺尚未完全实现。在医生和患者中，检索和交换医疗信息会增加感知到的工作量、负担和沮丧。这些增加并没有被传统的组织指标准确地捕捉到。这项研究提供了证据，为未来的人为因素工程研究提供了信息，以解决感知到的障碍，并指导未来的 HIE 设计或实施。
