title: 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.
  
  
  METHODS
  The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCP-reported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges.
  
  
  METHODS
  191 VHA PCPs from one regional network were surveyed (54% response rate), and 41 VHA PCPs and primary care staff were interviewed.
  PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed.
  
  
  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.
authors.affiliation: Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA, jessica.zuchowski@va.gov.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Zuchowski
authors.forename: Danielle E
authors.initials: DE
authors.lastname: Rose
authors.forename: Alison B
authors.initials: AB
authors.lastname: Hamilton
authors.forename: Susan E
authors.initials: SE
authors.lastname: Stockdale
authors.forename: Lisa S
authors.initials: LS
authors.lastname: Meredith
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Yano
authors.forename: Lisa V
authors.initials: LV
authors.lastname: Rubenstein
authors.forename: Kristina M
authors.initials: KM
authors.lastname: Cordasco
mesh_terms: D003142:Communication; D003430:Cross-Sectional Studies; D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D007400:Interprofessional Relations; D008511:Medicine / Q000379:methods / Q000592:standards*; D058007:Physicians, Primary Care / Q000592:standards*; D011320:Primary Health Care / Q000379:methods / Q000592:standards; D012017:Referral and Consultation / Q000592:standards*; D014481:United States; D014493:United States Department of Veterans Affairs / Q000592:standards*; D058014:Veterans Health / Q000592:standards