title: Towards successful coordination of electronic health record based-referrals: a qualitative analysis.
abstract: BACKGROUND
  Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may be challenging in the outpatient setting. Even when referrals are facilitated by electronic health records (EHRs) (i.e., e-referrals), lapses in patient follow-up might occur. Although compelling reasons exist why referral coordination should be improved, little is known about which elements of the complex referral coordination process should be targeted for improvement. Using Okhuysen & Bechky's coordination framework, this paper aims to understand the barriers, facilitators, and suggestions for improving communication and coordination of EHR-based referrals in an integrated healthcare system.
  
  
  METHODS
  We conducted a qualitative study to understand coordination breakdowns related to e-referrals in an integrated healthcare system and examined work-system factors that affect the timely receipt of subspecialty care. We conducted interviews with seven subject matter experts and six focus groups with a total of 30 PCPs and subspecialists at two tertiary care Department of Veterans Affairs (VA) medical centers. Using techniques from grounded theory and content analysis, we identified organizational themes that affected the referral process.
  
  
  RESULTS
  Four themes emerged: lack of an institutional referral policy, lack of standardization in certain referral procedures, ambiguity in roles and responsibilities, and inadequate resources to adapt and respond to referral requests effectively. Marked differences in PCPs' and subspecialists' communication styles and individual mental models of the referral processes likely precluded the development of a shared mental model to facilitate coordination and successful referral completion. Notably, very few barriers related to the EHR were reported.
  
  
  CONCLUSIONS
  Despite facilitating information transfer between PCPs and subspecialists, e-referrals remain prone to coordination breakdowns. Clear referral policies, well-defined roles and responsibilities for key personnel, standardized procedures and communication protocols, and adequate human resources must be in place before implementing an EHR to facilitate referrals.
authors.affiliation: Houston VA Health Services Research & Development Center of Excellence, Michael E, DeBakey Veterans Affairs Medical Center, Houaron, Texas, USA. sylvia.hysong@va.gov
authors.forename: Sylvia J
authors.initials: SJ
authors.lastname: Hysong
authors.forename: Adol
authors.initials: A
authors.lastname: Esquivel
authors.forename: Dean F
authors.initials: DF
authors.lastname: Sittig
authors.forename: Lindsey A
authors.initials: LA
authors.lastname: Paul
authors.forename: Donna
authors.initials: D
authors.lastname: Espadas
authors.forename: Simran
authors.initials: S
authors.lastname: Singh
authors.forename: Hardeep
authors.initials: H
authors.lastname: Singh
mesh_terms: D003266:Continuity of Patient Care / Q000592:standards*; D019033:Delivery of Health Care, Integrated / Q000592:standards; D057286:Electronic Health Records / Q000592:standards*; D017144:Focus Groups; D006302:Health Services Research; D006801:Humans; D007407:Interviews as Topic; D036301:Qualitative Research; D012017:Referral and Consultation / Q000592:standards*; D014584:User-Computer Interface