Digitally Enabled Transitional Care Management in Oncology.

PURPOSE: Improving care transitions for patients with cancer discharged from the hospital is considered an important component of quality care. Digital monitoring has the potential to better the delivery of transitional care through improved patient-provider communication and enhanced symptom management. However, remote patient monitoring (RPM) interventions have not been widely implemented for oncology patients after discharge, an innovative setting in which to apply this technology. METHODS: We implemented a RPM intervention which identifies medical oncology patients at discharge, monitors their symptoms for 10 days, and intervenes as necessary to manage symptoms. We evaluated the feasibility (>50% patient engagement with symptom assessment), appropriateness (symptom alerts), and acceptability (net promoter score >0.7) of the intervention and the initial effect on acute care visits and return on investment. RESULTS: During the study period, January 1, 2021, to December 31, 2022, we evaluated 2,257 medical oncology discharges representing 1,857 unique patients. We found that 65.9% of patients discharged (N = 1,489) completed at least one symptom assessment postdischarge and of them, 45.5% (n = 678) generated a severe symptom alert that we helped to manage. Patients expressed high satisfaction with the intervention with a net promoter score of 84%. In preliminary analysis of patients with GI malignancies (n = 449), we found a nonsignificant decrease in 30-day readmissions for the intervention cohort (n = 269) by 5.8% as compared with the control (n = 180; from 33.3% to 27.5%; P = .22). CONCLUSION: Digital transitional care management was feasible and demonstrated that patients transitioning from the hospital to home have a substantial symptom burden. The intervention was associated with high patient satisfaction but will require further refinement and evaluation to increase its impact on 30-day readmission.

Transitional care for patients with acute stroke-A priority-setting project.

BACKGROUND: The scope of this priority-setting process is communication and collaboration in transitional care for patients with acute stroke. Actively involving persons with stroke and their family caregivers is important both in transitional care and when setting priorities for research. Established priority-setting methods are time-consuming and require extensive resources. They are therefore not feasible in small-scale research. This article describes a pragmatic priority-setting process to identify a prioritized top 10 list of research needs regarding transitional care for patients with acute stroke. METHODS: A pragmatic priority-setting approach inspired by the James Lind Alliance was developed. It involves establishing a user group, identifying the research needs through an online survey, analysing and checking the research needs against systematic reviews, culminating in an online prioritization of the top 10 list. RESULTS: The process was completed in 7 months. A total of 122 patients, family caregivers, health personnel and caseworkers submitted 484 research needs, and 19 users prioritized the top 10 list. The list includes the categories 'patients and caregivers' needs and health literacy', 'health personnel's common understanding', 'information flow between health personnel and patients and caregivers', 'available interventions and follow-up of patients and caregivers', 'interaction and collaboration between health personnel and caseworkers across hospital and primary healthcare' and 'disabilities after stroke'. CONCLUSION: This paper outlines a pragmatic approach to identifying and prioritizing users' research needs that was completed in 7 months. The top 10 list resulting from this priority setting process can guide future research relating to communication and collaboration during the transition from hospital to the community for patients with stroke. PATIENT AND PUBLIC CONTRIBUTION: Members of three stroke organizations participated in the advisory group. They gave feedback on the scope and the process, distributed the surveys and prioritized the top 10 list. Persons with stroke and their caregivers submitted research needs in the survey.

Evaluation of a new transition organization for young adults with endocrine or metabolic diseases.

OBJECTIVE: To evaluate the effect of a new care organization on multiple outcomes of transition success and its cost-effectiveness in patients with any endocrine or metabolic disease diagnosed during childhood and transferred to adult care. DESIGN: Non-randomized controlled trial in a French university hospital. METHODS: Patients transferred to adult care during the control period (04/2014-08/2016) and the intervention period (09/2016-06/2018) were included. The intervention is based on case management involving liaising with pediatric services, personalizing care pathways, and liaising with structures outside hospital (general practitioner, educational and social sector). The primary endpoint was the percentage of patients lost to follow-up at 24 months post transfer. Other outcomes were collected from medical files, consultation software, and questionnaires. A cost analysis was performed. RESULTS: Two hundred two patients were included (101 per period), the most represented pathologies were congenital and non-congenital hypopituitarism (respectively n = 34 (17%) and n = 45 (22%)) and thyroid diseases (n = 21, 10%). Patients were aged 22.5 in median at 24 months post transfer where 12 were lost to follow-up in the control group vs 9 with the intervention (P = 0.49). The percentage of honored consultation among those planned during 24 months was higher with intervention (P = 0.0065). Patient satisfaction, physician trust, and transfer delay did not differ between the groups. The incremental cost-effectiveness ratio was €179 per patient not lost to follow-up. CONCLUSIONS: At 24 months post transfer, the rate of lost to follow-up did not differ significantly, but indicators of a steadier follow-up were increased and the intervention appeared to be cost-effective.

Opening Pandora's Box: From Readmissions to Transitional Care Patient-Centered Outcome Measures.

BACKGROUND: Measuring the effectiveness of transitional care interventions has historically relied on health care utilization as the primary outcome. Although the Care Transitions Measure was the first outcome measure specifically developed for transitional care, its applicability beyond the hospital-to-home transition is limited. There is a need for patient-centered outcome measures (PCOMs) to be developed for transitional care settings (ie, TC-PCOMs) to ensure that outcomes are both meaningful to patients and relevant to the particular care transition. The overall objective of this paper is to describe the opportunities and challenges of integrating TC-PCOMs into research and practice. METHODS AND RESULTS: This narrative review was conducted by members of the Patient-Centered Outcomes Research Institute (PCORI) Transitional Care Evidence to Action Network. We define TC-PCOMs as outcomes that matter to patients because they account for their individual experiences, concerns, preferences, needs, and values during the transition period. The cardinal features of TC-PCOMs should be that they are developed following direct input from patients and stakeholders and reflect their lived experience during the transition in question. Although few TC-PCOMs are currently available, existing patient-reported outcome measures could be adapted to become TC-PCOMs if they incorporated input from patients and stakeholders and are validated for the relevant care transition. CONCLUSION: Establishing validated TC-PCOMs is crucial for measuring the responsiveness of transitional care interventions and optimizing care that is meaningful to patients.

Implementation of Complex Interventions: Lessons Learned From the Patient-Centered Outcomes Research Institute Transitional Care Portfolio.

BACKGROUND: Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging. OBJECTIVE: The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care. RESEARCH DESIGN: Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research. RESULTS: Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results. CONCLUSION: These lessons can help guide future pragmatic studies of care transitions.

Effectiveness of a nurse-led hospital-to-home transitional care intervention for older adults with multimorbidity and depressive symptoms: A pragmatic randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of a nurse-led hospital-to-home transitional care intervention versus usual care on mental functioning (primary outcome), physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use costs in older adults with multimorbidity (≥ 2 comorbidities) and depressive symptoms. DESIGN AND SETTING: Pragmatic multi-site randomized controlled trial conducted in three communities in Ontario, Canada. Participants were allocated into two groups of intervention and usual care (control). PARTICIPANTS: 127 older adults (≥ 65 years) discharged from hospital to the community with multimorbidity and depressive symptoms. INTERVENTION: This evidence-based, patient-centred intervention consisted of individually tailored care delivery by a Registered Nurse comprising in-home visits, telephone follow-up and system navigation support over 6-months. OUTCOME MEASURES: The primary outcome was the change in mental functioning, from baseline to 6-months. Secondary outcomes were the change in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use cost, from baseline to 6-months. Intention-to-treat analysis was performed using ANCOVA modeling. RESULTS: Of 127 enrolled participants (63-intervention, 64-control), 85% had six or more chronic conditions. 28 participants were lost to follow-up, leaving 99 (47 -intervention, 52-control) participants for the complete case analysis. No significant group differences were seen for the baseline to six-month change in mental functioning or other secondary outcomes. Older adults in the intervention group reported receiving more information about health and social services (p = 0.03) compared with the usual care group. CONCLUSIONS: Although no significant group differences were seen for the primary or secondary outcomes, the intervention resulted in improvements in one aspect of patient experience (information about health and social services). The study sample fell below the target sample (enrolled 127, targeted 216), which can account for the non-significant findings. Further research on the impact of the intervention and factors that contribute to the results is recommended. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03157999.

Checklist for follow-up of adolescents with chronic illness. A monitoring tool to help prepare the transition from pediatric to adult care.

Adolescence can be a particularly challenging period for individuals with a chronic illness. To help the specialized healthcare teams, an expert panel drafted a checklist of topics to be addressed throughout adolescence that are often not covered in subspecialty clinic visits such as peers, coping, adherence, understanding of illness, sexuality, etc., since these topics apply to youth with special healthcare needs. Each member of the specialized team can discuss one of the themes according to their role with the adolescent as a doctor, educator, nurse, dietician, etc. The coherence of the team enables a comprehensive approach and will facilitate the transition to adult medical care.

Transition from pediatric to adult aftercare for survivors of pediatric cancer in Newfoundland and Labrador: a qualitative study.

BACKGROUND: Childhood cancer survivors (CCSs) face increased risks during the period when they leave pediatric care and transition into adult-focused aftercare. We examined the experiences of CCSs entering adult-focused aftercare to gain a better understanding of current transition practices and barriers to transition, and to identify opportunities for improving care. METHODS: We conducted a qualitative study using in-person and telephone semi-structured interviews. Childhood cancer survivors who recently transitioned out of pediatric care and health care providers (HCPs) who provide care for CCSs in Newfoundland and Labrador were identified using purposive sampling. Participants were interviewed between July 2017 and March 2019. Data were analyzed using both qualitative descriptive and thematic analysis. RESULTS: We conducted interviews with 5 CCSs and 9 HCPs. All CCSs interviewed reported receiving aftercare through their pediatric oncology program; only 2 reported receiving any form of aftercare in the adult setting. The lack of a structured transition process for CCSs in the province emerged as a theme in this study. Interview participants identified several barriers to transition: the added challenges for survivors in rural areas, changes in the availability of services after the transition to adult-focused aftercare, challenges associated with navigating the adult system, and a lack of education on transitioning into adult aftercare. INTERPRETATION: We found that there was little preparation for the transition of CCSs into adult care, and their aftercare was disrupted. Programs serving CCSs have opportunities to improve care by standardizing and better supporting these transitions, for example through the development of context-appropriate educational resources.

Eastern association for the surgery of trauma - quality, patient safety, and outcomes committee - transitions of care: healthcare handoffs in trauma.

BACKGROUND: Handoffs are defined as the transfer of patient information, professional responsibility, and accountability between caregivers. This work aims to clarify the current state of transitions of care related to the management of trauma patients. METHODS: A PubMed database and web search were performed for articles published between 2000 and 2020 related to handoffs and transitions of care. The key search terms used were: handoff(s), handoff(s) AND healthcare, and handoff(s) AND trauma. A total of 55 studies were included in qualitative synthesis. RESULTS: This systematic review explores the current state of healthcare handoffs for trauma patients. Factors found to impact successful handoffs included process standardization, team member accountability, effective communication, and the incorporation of culture. This review was limited by the small number of prospective randomized studies available on the topic. CONCLUSION: Handoffs in trauma care have been studied and should be utilized in the context of published experience and practice. Standardization when applied with accountability has proven benefit to reduce communication errors during these transfers of care.

Information Sharing Practices Between US Hospitals and Skilled Nursing Facilities to Support Care Transitions.

Importance: Patient transitions from hospitals to skilled nursing facilities (SNFs) require robust information sharing. After a decade of investment in health information technology infrastructure and new incentives to promote hospital-SNF coordination in the US, the current state of information sharing at this critical transition is unknown. Objective: To measure the completeness, timeliness, and usability of information shared by hospitals when discharging patients to SNFs, and to identify relational and structural characteristics associated with better hospital-SNF information sharing. Design, Setting, and Participants: Survey of 500 SNFs from a US nationally representative sample (265 respondents representing 471 hospital-SNF pairs; response rate of 53.0%) that collected detailed data on information sharing that supports care transitions from each of the 2 hospitals from which they receive the largest volume of patient referrals. Survey administration occurred between January 2019 and March 2020. Main Outcomes and Measures: Overall assessment of information completeness, timeliness, and usability using 5-point Likert scales. Detailed measures, including (1) completeness-routine sharing of 23 specific information types; (2) timeliness-how often information arrived after the patient; and (3) usability-whether information was duplicative, extraneous, or not tailored to SNF needs. In addition, 8 relational characteristics (eg, shared staffing, collaborative meetings, and referral volume) and 10 structural characteristics (eg, size, ownership, and staffing) were assessed as potential factors associated with better information sharing. Results: Of 471 hospital-SNF pairs, 64 (13.5%) reported excellent performance on all 3 dimensions of information sharing, whereas 141 (30.0%) were at or below the mean performance on all dimensions. Social status (missing in 309 pairs [65.7%]) and behavioral status (missing in 319 pairs [67.7%]) were the most common types of missing information. Receipt of hospital information was delayed, sometimes (159 pairs [33.8%]) or often (77 pairs [16.4%]) arriving after the patient. In total, 358 pairs [76.0%] reported at least 1 usability shortcoming. Having a hospital clinician on site at the SNF was associated in multivariate analysis with more complete (odds ratio, 1.72; 95% CI, 1.07-2.78; P = .03), timely (odds ratio, 1.76; 95% CI, 1.08-2.88; P = .02), and usable (odds ratio, 1.64; 95% CI, 1.02-2.63; P = .04) information sharing. Hospital accountable care organization participation was associated with more timely information sharing (odds ratio, 1.88; 95% CI, 1.13-3.14; P = .02). Conclusions and Relevance: In this study, US SNFs reported significant shortcomings in the completeness, timeliness, and usability of information provided by hospitals to support patient transitions. These shortcomings are likely associated with a suboptimal transition experience. Shared clinicians represent a potential strategy to improve information sharing but are costly. New payment models such as accountable care organizations may offer a more scalable approach but were only associated with more timely sharing.

Using the Preparedness Assessment for the Transition Home After Stroke Instrument to Identify Stroke Caregiver Concerns Predischarge: Uncertainty, Anticipation, and Cues to Action.

PURPOSE: The aim of the study was to better understand caregivers' concerns about long-term implications of stroke and the caregiving role after completing the Preparedness Assessment for the Transition Home After Stroke (PATH-s). DESIGN/METHODS: In this qualitative study, cognitive interviews were conducted with 20 stroke caregivers who completed the PATH-s tool as part of an instrument validation study. Data were analyzed for salient themes related to their perceptions about stroke and the caregiving role. FINDINGS: Interviews yielded robust narrative data describing how the PATH-s items aided caregivers in recognizing potential issues and concerns about stroke and the caregiving role. Caregivers experienced uncertainty about the long-term stroke prognosis, which provoked anticipation and cues to action to begin addressing their concerns. CONCLUSIONS/CLINICAL RELEVANCE: Completing the PATH-s helped caregivers identify concerns regarding the long-term implications of stroke and their caregiving role. It may serve as an important assessment tool to assist rehabilitation nurses to better understand and address caregiver needs predischarge.

Burdensome Transitions of Care for Patients with End-Stage Liver Disease and Their Caregivers.

BACKGROUND: Patients with end-stage liver disease (ESLD) experience frequent readmissions; however, studies focused on patients' and caregivers' perceptions of their transitional care experiences to identify root causes of burdensome transitions of care are lacking. AIM: To explore the transitional care experiences of patients with ESLD and their caregivers in order to identify their supportive care needs. METHODS: We conducted interviews with 15 patients with ESLD and 14 informal caregivers. We used semi-structured interview guides to explore their experiences since the diagnosis of ESLD including their care transitions. Two raters coded interviews independently (κ = 0.95) using template analysis. RESULTS: Participants reported feeling unprepared to manage their informational, psychosocial, and practical care needs as they transitioned from hospital to home after the diagnosis of ESLD. Delay in the timely receipt of supportive care services addressing these care needs resulted in hospital readmissions, emotional distress, caregiver burnout, reduced work capacity, and financial hardship. Participants shared the following resources that they perceived would improve their quality of care: (1) discharge checklist, (2) online resources, (3) mental health support, (4) caregiver support and training, and (5) financial navigation. CONCLUSION: Transitional care models that attend to the informational, psychosocial, and practical domains of care are needed to better support patients with ESLD and their caregivers at the time of diagnosis and beyond. Without attending to the multidimensional care needs of newly diagnosed patients with ESLD and their caregivers, they are at risk of burdensome transitions of care, high healthcare utilization, and poor health-related quality of life.

Stroke systems of care in high-income countries: what is optimal?

Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.

Transitional care from hospital to home for older people: implementation of best practices.

OBJECTIVE: to assess the conformity of nursing care concerning best evidence in transitional care from hospital to home for older people. METHODS: a project to implement best evidence based on the model proposed by the Joanna Briggs Institute in surgical clinic of a university hospital with older people, caregivers or family members, and nurses, between July and August 2019. Eight evidence-based criteria have been audited through interviews, medical records and computerized system, presented in percentages. RESULTS: the highest non-compliance rate found in a baseline audit was absence of continued training on transitional care and hospital discharge plan. Identifying barriers to best practices included educational programs; afterwards, there was an improvement in compliance rates in all the criteria assessed. FINAL CONSIDERATIONS: the criteria based on audited evidence showed an increase in compliance rates with the strategies implemented, contributing to improving transitional care for older people.

Cost-effectiveness analysis of systematic fast-track transition from oncological treatment to specialised palliative care at home for patients and their caregivers: the DOMUS trial.

BACKGROUND: While hospitals remain the most common place of death in many western countries, specialised palliative care (SPC) at home is an alternative to improve the quality of life for patients with incurable cancer. We evaluated the cost-effectiveness of a systematic fast-track transition process from oncological treatment to SPC enriched with a psychological intervention at home for patients with incurable cancer and their caregivers. METHODS: A full economic evaluation with a time horizon of six months was performed from a societal perspective within a randomised controlled trial, the DOMUS trial ( Clinicaltrials.gov : NCT01885637). The primary outcome of the health economic analysis was a incremental cost-effectiveness ratio (ICER), which is obtained by comparing costs required per gain in Quality-Adjusted Life Years (QALY). The costs included primary and secondary healthcare costs, cost of intervention and informal care from caregivers. Public transfers were analysed in seperate analysis. QALYs were measured using EORTC QLQ-C30 for patients and SF-36 for caregivers. Bootstrap simulations were performed to obtain the ICER estimate. RESULTS: In total, 321 patients (162 in intervention group, 159 in control group) and 235 caregivers (126 in intervention group, 109 in control group) completed the study. The intervention resulted in significantly higher QALYs for patients when compared to usual care (p-value = 0.026), while being more expensive as well. In the 6 months observation period, the average incremental cost of intervention compared to usual care was €2015 per patient (p value < 0.000). The mean incremental gain was 0.01678 QALY (p-value = 0.026). Thereby, the ICER was €118,292/QALY when adjusting for baseline costs and quality of life. For the caregivers, we found no significant differences in QALYs between the intervention and control group (p-value = 0.630). At a willingness to pay of €80,000 per QALY, the probability that the intervention is cost-effective lies at 15% in the base case scenario. CONCLUSION: This model of fast-track SPC enriched with a psychological intervention yields better QALYs than usual care with a large increase in costs. TRIAL REGISTRATION: The trial was prospectively registered 25.6.2013. Clinicaltrials.gov Identifier: NCT01885637 .

Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review.

BACKGROUND: Demographic changes are taking place in most industrialized countries. Geriatric patients are defined by the European Union of Medical Specialists as aged over 65 years and suffering from frailty and multi-morbidity, whose complexity puts a major burden on these patients, their family caregivers and the public health care system. To counteract negative outcomes and to maintain consistency in care between hospital and community dwelling, the transitional of care has emerged over the last several decades. Our objectives were to identify and summarize the components of the Transitional Care Model implemented with geriatric patients (aged over 65 years, with multi-morbidity) for the reduction of all-cause readmission. Another objective was to recognize the Transitional Care Model components' role and impact on readmission rate reduction on the transition of care from hospital to community dwelling (not nursing homes). METHODS: Randomized controlled trials (sample size ≥50 participants per group; intervention period ≥30 days), with geriatric patients were included. Electronic databases (MEDLINE, CINAHL, PsycINFO and The Cochrane Central Register of Controlled Trials) were searched from January 1994 to December 2019 published in English or German. A qualitative synthesis of the findings as well as a systematic assessment of the interventions intensities was performed. RESULTS: Three articles met the inclusion criteria. One of the included trials applied all of the nine Transitional Care Model components described by Hirschman and colleagues and obtained a high-intensity level of intervention in the intensities assessment. This and another trial reported reductions in the readmission rate (p < 0.05), but the third trial did not report significant differences between the groups in the longer follow-up period (up to 12 months). CONCLUSIONS: Our findings suggest that high intensity multicomponent and multidisciplinary interventions are likely to be effective reducing readmission rates in geriatric patients, without increasing cost. Components such as type of staffing, assessing and managing symptoms, educating and promoting self-management, maintaining relationships and fostering coordination seem to have an important role in reducing the readmission rate. Research is needed to perform further investigations addressing geriatric patients well above 65 years old, to further understand the importance of individual components of the TCM in this population.

Crossing boundaries: Establishing a framework for researching quality and safety in care transitions.

BACKGROUND: Despite the breadth and diversity of research and policies on care transitions, research studies often report similar components that affect the quality and safety of care, including communication across professional groups and care settings, transfer of information, coordination of resources or training of healthcare personnel. In this article, we aim to deepen our understanding of care transitions by proposing a heuristic research framework that takes into account the components and factors influencing the quality and safety of care transitions in diverse settings. METHODOLOGY: Using a pragmatic qualitative narrative meta-synthesis of empirically grounded research studies (N = 13) involving 31 researchers from seven countries (Australia, Canada, Denmark, Germany, the Netherlands, Norway and the UK), we conducted a thematic analysis to identify the components analysed in the included studies. We then used these components to create a framework for researching care transitions. RESULTS: Our narrative synthesis found that the quality and safety of care transitions are influenced by a range of patient-centred, communicative, collaborative, cultural, competency-based, accountability-based and spatial components. These components are encompassed within a broader set of dimensions that require careful consideration: (1) the conceptualising of the care transition notion, (2) the methodology for researching care transitions, (3) the role of patients and carers in care transitions, (4) the complexity surrounding care transitions, (5) the boundaries intertwined in care transitions and (6) care transition improvement interventions. These six dimensions constitute an analytical framework for planning and conducting research on care transitions in diverse settings. CONCLUSION: The proposed six-dimensional framework for researching quality and safety in care transitions offers a roadmap for future practice and policy interventions and provides a starting point for planning and designing future research.

Gains, losses, and uncertainties from computerizing referrals and consultations.

Consultations entail transitions in care between referrers and consultants, as patients visit different clinicians and care sites. This complex process has been consistently prone to communication breakdowns. Despite expectations and benefits of electronic health records (EHRs), incomplete, vague, or inappropriate referrals continue to hinder consultations; referrals can be sent to the wrong specialty service; and consultation findings frequently fail to reach referrers. Due to the inadequate support of interpersonal communication afforded by EHRs, these issues persist. Important aspects of ergonomics and human factors engineering frequently appear overlooked during the design and implementation of EHRs. Usability issues have contributed to delays in medical diagnosis, treatment, and follow-up. Some of these delays contribute to patient harms. Our multidisciplinary team of clinicians and ergonomics professionals reflects on referral and consultation. We describe how computerization in healthcare should benefit from approaches informed and developed through applied ergonomics and human factors.