Skip to main content

Hidden complexities in information flow between primary and specialty care clinics

Abstract

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.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

Notes

  1. 1.

    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.

References

  1. Bennett KB, Flach JM (2011) Display and interface design. Subtle science and exact art. CRC Press, Boca Raton

    Google Scholar 

  2. Blandford A, Furniss D, Vincent C (2014) Patient safety and interactive medical devices: realigning work as imagined and work as done. Clinical risk 20(5):107–110

    Article  Google Scholar 

  3. Borst C, Flach JM, Ellerbroek J (2015) Beyond ecological interface design: Lessons from concerns and misconceptions. IEEE Trans Human Mach Syst 45(2):164–175

    Article  Google Scholar 

  4. Department of Veterans Affairs Office of Information & Technology Product Development (2016) Consult/request tracking user manual. Washington DC: Department of Veterans Affairs. https://www.va.gov/vdl/documents/Clinical/CPRS-Consult_Request_Tracking/consum.pdf

  5. Flach JM, Bennett KB, Woods DD, Jagacinski RJ (2015) Interface Design: A Control Theoretic Context for a Triadic Meaning Processing Approach. Cambri Handb Appl Percept Res 32:647–668

    Article  Google Scholar 

  6. Green J, Thorogood N (2013) Qualitative methods for health research. Sage, Los Angeles

    Google Scholar 

  7. Hawkins M (2017) Survey of physician appointment wait times and medicaid and medicare acceptance rates. Merritt Hawkins, Irving

    Google Scholar 

  8. Hoffman R, Militello LG (2008) Perspectives on cognitive task analysis: historical origins and modern communities of practice. Taylor and Francis, New York

    Google Scholar 

  9. Hollnagel E (August 2014) Why WAI is different from WAD. In: Presented at the third resilience health care net meeting. Middlefart, Denmark, pp 12–14

  10. Humphrey CM, Adams JA (2013) Cognitive information flow analysis. Cogn Technol Work 15(2):133–152

    Article  Google Scholar 

  11. Hysong SJ, Esquivel A, Sittig DF, Paul LA, Espadas D, Singh S, Singh H (2011) Towards successful coordination of electronic health record based-referrals: a qualitative analysis. Implement Sci 6(1):84

    Article  Google Scholar 

  12. Militello LG, Patterson ES, Bowman L, Wears R (2007) Information flow during crisis management: challenges to coordination in the emergency operations center. Cogn Technol Work 9(1):25–31

    Article  Google Scholar 

  13. Militello LG, Diiulio J, Russ AL, Savoy A, Flanagan ME, Patel H, Weiner M (2016). Design Concepts to support management of consultations in the veterans health adminstration. In: Extended Abstract in Proceedings of the Human Factors and Ergonomics Society, 60(1), 1475–1476. Los Angeles: Sage

  14. Miller A, Militello LG (2015) The role of cognitive engineering in improving clinical decision support. In: Bisantz AM, Burns CM, Fairbanks RJ (eds) Cognitive engineering applications in health care. CRC Press, New York

    Google Scholar 

  15. Naikar N, Hopcroft R, Moylan A (2005) Work domain analysis: Theoretical concepts and methodology. No. DSTO-TR-1665. Defence Science and Technology Organisation Victoria (Australia) Air Operation Division, Victoria

  16. Oppel RA (June 20, 2015) Wait lists grow as many more veterans seek care and funding falls short. New York Times. https://www.nytimes.com/2015/06/21/us/wait-lists-grow-as-many-more-veterans-seek-care-and-funding-falls-far-short.html?_r=0

  17. Saleem JJ, Russ AL, Justice CF, Hagg H, Ebright PR, Woodbridge PA, Doebbeling BN (2009) Exploring the persistence of paper with the electronic health record. Int J Med Inf 78(9):618–628

    Article  Google Scholar 

  18. Schultz K, Carayon P, Hundt AS, Springman SR (2007) Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information flow and their consequences. Cogn Technol Work 9(4):219–231

    Article  Google Scholar 

  19. Singh H, Esquivel A, Sittig DF, Murphy D, Kadiyala H, Schiesser R et al (2011) Follow-up actions on electronic referral communication in a multispecialty outpatient setting. J Gen Intern Med 26(1):64–69

    Article  Google Scholar 

  20. Smith SW, Koppel R (2013) Healthcare information technology’s relativity problems: a typology of how patients’ physical reality, clinicians’ mental models, and healthcare information technology differ. J Am Med Inform Assoc 21(1):117–131

    Article  Google Scholar 

  21. Wagner EH, Sandhu N, Coleman K, Phillips KE, Sugarman JR (2014) Improving care coordination in primary care. Med Care 1;52:S33-8

    Google Scholar 

  22. Wu J, Militello LG, Flanagan ME, Barker B, Rehman S, Porter BW, Weiner M (2016) Barriers and facilitators to using electronic health records for referrals between primary and specialty care clinics. In: Proceedings of the American Medical Informatics Association Annual Symposium, Washington DC: AMIA

  23. Xiao Y, Hu P, Moss J, de Winter JC, Venekamp D, Mackenzie CF, … Perkins S (2008) Opportunities and challenges in improving surgical work flow. Cogn Technol Work 10(4):313–321

    Article  Google Scholar 

Download references

Acknowledgements

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.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Laura G. Militello.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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). https://doi.org/10.1007/s10111-018-0486-y

Download citation

Keywords

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