Facilitators and barriers to implementing electronic referral and/or consultation systems: a qualitative study of 16 health organizations.

BACKGROUND: Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery. METHODS: Interviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts. RESULTS: Electronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows. CONCLUSIONS: eCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives.

Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering.

BACKGROUND: Displaying radiation exposure and cost information at electronic order entry may encourage clinicians to consider the value of diagnostic imaging. METHODS: An urban safety-net health system displayed radiation exposure information for CT and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering. We assessed whether there were differences in numbers of outpatient CT scans and MRIs per month relative to ultrasounds before and after the intervention, and evaluated primary care clinicians' responses to the intervention. RESULTS: There were 23 171 outpatient CTs, 15 052 MRIs and 43 266 ultrasounds from 2011 to 2014. The ratio of CTs to ultrasounds decreased by 15% (95% CI 9% to 21%), from 58.2 to 49.6 CTs per 100 ultrasounds; the ratio of MRIs to ultrasounds declined by 13% (95% CI 7% to 19%), from 37.5 to 32.5 per 100. Of 300 invited, 190 (63%) completed the web-based survey in 17 clinics. 154 (81%) noticed the radiation exposure information and 158 (83.2%) noticed the cost information. Clinicians believed radiation exposure information was more influential than cost information: when unsure clinically about ordering a test (radiation=69.7%; cost=46.4%), when a patient wanted a test not clinically indicated (radiation=77.5%; cost=54.8%), when they had a choice between imaging modalities (radiation=77.9%; cost=66.6%), in patient care discussions (radiation=71.9%; cost=43.2%) and in trainee discussions (radiation=56.5%; cost=53.7%). Resident physicians and nurse practitioners were more likely to report that the cost information influenced them (p<0.05). CONCLUSIONS: Displaying radiation exposure and cost information at order entry may improve clinician awareness about diagnostic imaging safety risks and costs. More clinicians reported the radiation information influenced their clinical practice.

Leveraging an electronic referral system to build a medical neighborhood.

BACKGROUND: Electronic referral and consultation systems are gaining popularity, but their contribution to the patient centered medical home-neighborhood framework of coordinated care delivery is not clear. We examined how specialists leverage an electronic referral and consultation system to deliver specialty care, identified determinants of high-quality electronic specialist communication and measured the impact of feedback to specialists on communication quality. METHODS: Referral patterns were identified for 19 specialties using eReferral in the San Francisco public health care delivery system. Primary care provider (PCP) ratings of the quality (helpfulness and educational value) of consultative communication were measured. Using logistic regression, we identified determinants of high-quality specialist communication during pre-consultative exchange or virtual co-management. Predictors included: specialty and reviewer type, referral volume, percent of referrals never scheduled and time spent by reviewers on eReferral. A pre-post analysis examined the impact of feedback on communication quality. RESULTS: The percentage of referrals immediately scheduled (27.2-82.8%) and never scheduled (7.7-59.3%) varied by specialty, with medical reviewers (vs. surgical and women׳s health) and physician reviewers (vs. nurse practitioners) scheduling fewer referrals immediately (p<0.001). Prevalence of high-quality communication was 71%, impacted by referral volume (adjusted odds ratio=0.78, 95%CI 0.68-0.88 for each additional 1000 referrals/year) and time spent per referral (1.18, 1.04-1.35 for each additional 3min). CONCLUSIONS: Specialists can use electronic referral and consultation systems to enhance specialty care delivery with consultative communication that is highly rated by PCPs. IMPLICATIONS: These data can inform the structure and functionality of future electronic consultation systems to maximize care coordination. LEVEL OF EVIDENCE: III.

Increasing access to specialty care: patient discharges from a gastroenterology clinic.

OBJECTIVES: Access to specialty care among safety net patients in the United States is inadequate. Discharging appropriate patients to routine primary care follow-up may improve specialty care access. We sought to identify, by consensus, patients who could safely be discharged from a gastroenterology (GI) clinic, and to evaluate the impact of the discharges on GI clinic work flow. STUDY DESIGN: Pre- and post intervention. METHODS: We developed and implemented a modified Delphi process. Gastroenterologists and primary care providers (PCPs) rated their comfort (using 5-point Likert scales) with discharging patients immediately post endoscopy for 24 clinical scenarios, assuming formal recommendations were communicated to the PCP. We examined the impact of implementing these criteria on clinic wait times and on the ratio of new to follow-up visits. RESULTS: All gastroenterologists (100%; 7 of 7) and 71.0% of PCPs (130 of 183) participated. Consensus was achieved for 13 of the 24 clinical scenarios for which discharge criteria were developed. Post intervention, 403 patients were discharged from the GI clinic, compared with 0 patients in the same 4 calendar months pre-intervention. The ratio of new to follow-up appointments increased from 0.9:1 to 1:1 (P = .05). Median wait time for the third next available appointment at GI clinics decreased from 158 days to 74 days (P = .0001). CONCLUSIONS: Discharging patients from specialty care back to primary care with consensus standards is one method to improve access to specialty care. Understanding the concerns of all stakeholders is necessary to refine and disseminate this process to other specialties and healthcare systems to ensure timely access to specialty services for all patients.

Clinicians' views on displaying cost information to increase clinician cost-consciousness.

OBJECTIVES: To evaluate 1) clinician attitudes towards incorporating cost information into decision making when ordering imaging studies; and 2) clinician reactions to the display of Medicare reimbursement information for imaging studies at clinician electronic order entry. STUDY DESIGN: Focus group study with inductive thematic analysis. METHODS: We conducted focus groups of primary care clinicians and subspecialty physicians (nephrology, pulmonary, and neurology) (N = 50) who deliver outpatient care in 12 hospital-based clinics and community health centers in an urban safety net health system. We analyzed focus group transcripts using an inductive framework to identify emergent themes and illustrative quotations. RESULTS: Clinicians believed that their knowledge of healthcare costs was low and wanted access to relevant cost information for reference. However, many clinicians believed it was inappropriate and unethical to consider costs in individual patient care decisions. Among clinicians' negative reactions toward displaying costs at order entry, 4 underlying themes emerged: 1) belief that ordering is already limited to clinically necessary tests; 2) importance of prioritizing responsibility to patients above that to the healthcare system; 3) concern about worsening healthcare disparities; and 4) perceived lack of accountability for healthcare costs in the system. CONCLUSIONS: Although clinicians want relevant cost information, many voiced concerns about displaying cost information at clinician order entry in safety net health systems. Alternative approaches to increasing cost-consciousness may be more acceptable to clinicians.

Clinician perspectives on considering radiation exposure to patients when ordering imaging tests: a qualitative study.

BACKGROUND AND OBJECTIVES: Increased computer tomography (CT) scan use has contributed to a rise in medically-associated radiation exposure. The extent to which clinicians consider radiation exposure when ordering imaging tests is unknown. We examined (1) outpatient clinician attitudes towards considering radiation exposure when ordering CT scans; and (2) clinician reactions to displaying radiation exposure information for CT scans at clinician electronic order entry. METHODS: We conducted nine focus groups with primary care clinicians and subspecialty physicians (nephrology, pulmonary and neurology) (n=50) who deliver outpatient care across 12 hospital-based clinics and community health centres in an urban safety-net health system, which use a common electronic order entry system. We analysed focus group transcripts using an inductive framework to identify emergent themes and illustrative quotations. FINDINGS: Clinicians felt they had limited knowledge of the clinical implications of radiation exposure. Many believed clinically relevant information such as the increased risk of malignancy from CT scans would be useful to inform decision-making and patient-clinician discussions. Clinicians noted that patient vulnerability and long wait times for tests with less radiation exposure (such as MRI or ultrasound) often acted as barriers to minimise patient radiation exposure from CT scans. Clinicians suggested providing patients' cumulative radiation exposure or formal decision aids to improve the usefulness of the radiation exposure information. CONCLUSIONS: Displaying clinically relevant radiation exposure information at order entry may improve clinician knowledge and inform patient-clinician discussions regarding risks and benefits of imaging. However, limited access to tests with lower radiation exposure in safety-net settings may trump efforts to minimise patient radiation exposure.