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Hidden complexities in information flow between primary and specialty care clinics


Consultations are a critical part of healthcare for many patients; however, they pose macrocognitive challenges at both individual and system levels. Coordination between primary care and specialty clinics is challenging, because information must be shared across clinics, roles, and time. We conducted a study of the consultations process in the U.S. Department of Veterans Affairs. Using interviews, observations, and document review, we identified five limitations in the current documentation of information flow: scheduling is omitted, information transfers appear to be standardized and well understood, all information relevant to consultations appears to be efficiently tracked from beginning to end, CPRS appears to support critical communication about consultations, and follow-up is de-emphasized. We offer a more ecologically oriented, descriptive model of information flow, and highlight common breakdowns in the consultations process.

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    TIU refers to the Text Integration Utilities package used for managing clinical documents. It is generally not available to end-users such as clinicians and staff.


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This work was supported by VA HSR&D Grant No. IIR #12–102 and the Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13–416. Views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs or the U.S. government.

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Correspondence to Laura G. Militello.

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Militello, L.G., Savoy, A., Porter, B. et al. Hidden complexities in information flow between primary and specialty care clinics. Cogn Tech Work 20, 565–574 (2018).

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  • Coordination
  • Health
  • Consultations
  • Information flow
  • Ecological design