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Abstract Electronic health records are increasingly being used to facilitate referral communication in the outpatient setting. However, despite support by technology, referral communication between primary care providers and specialists is often unsatisfactory and is unable to eliminate care delays. This may be in part due to lack of attention to how information and communication technology fits within the social environment of health care. Making electronic referral communication effective requires a multifaceted “socio-technical” approach. Using an 8-dimensional socio-technical model for health information technology as a framework, we describe ten recommendations that represent good clinical practices to design, develop, implement, improve, and monitor electronic referral communication in the outpatient setting. These recommendations were developed on the basis of our previous work, current literature, sound clinical practice, and a systems-based approach to understanding and implementing health information technology solutions. Recommendations are relevant to system designers, practicing clinicians, and other stakeholders considering use of electronic health records to support referral communication.

Abstract Background Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may be challenging in the outpatient setting. Even when referrals are facilitated by electronic health records (EHRs) (i.e., e-referrals), lapses in patient follow-up might occur. Although compelling reasons exist why referral coordination should be improved, little is known about which elements of the complex referral coordination process should be targeted for improvement. Using Okhuysen & Bechky's coordination framework, this paper aims to understand the barriers, facilitators, and suggestions for improving communication and coordination of EHR-based referrals in an integrated healthcare system. Methods We conducted a qualitative study to understand coordination breakdowns related to e-referrals in an integrated healthcare system and examined work-system factors that affect the timely receipt of subspecialty care. We conducted interviews with seven subject matter experts and six focus groups with a total of 30 PCPs and subspecialists at two tertiary care Department of Veterans Affairs (VA) medical centers. Using techniques from grounded theory and content analysis, we identified organizational themes that affected the referral process. Results Four themes emerged: lack of an institutional referral policy, lack of standardization in certain referral procedures, ambiguity in roles and responsibilities, and inadequate resources to adapt and respond to referral requests effectively. Marked differences in PCPs' and subspecialists' communication styles and individual mental models of the referral processes likely precluded the development of a shared mental model to facilitate coordination and successful referral completion. Notably, very few barriers related to the EHR were reported. Conclusions Despite facilitating information transfer between PCPs and subspecialists, e-referrals remain prone to coordination breakdowns. Clear referral policies, well-defined roles and responsibilities for key personnel, standardized procedures and communication protocols, and adequate human resources must be in place before implementing an EHR to facilitate referrals.

Abstract Background Health information technology and electronic medical records (EMRs) are potentially powerful systems-based interventions to facilitate diagnosis and treatment because they ensure the delivery of key new findings and other health related information to the practitioner. However, effective communication involves more than just information transfer; despite a state of the art EMR system, communication breakdowns can still occur. 123 In this project, we will adapt a model developed by the Systems Engineering Initiative for Patient Safety (SEIPS) to understand and improve the relationship between work systems and processes of care involved with electronic communication in EMRs. We plan to study three communication activities in the Veterans Health Administration's (VA) EMR: electronic communication of abnormal imaging and laboratory test results via automated notifications (i.e., alerts); electronic referral requests; and provider-to-pharmacy communication via computerized provider order entry (CPOE). Aim Our specific aim is to propose a protocol to evaluate the systems and processes affecting outcomes of electronic communication in the computerized patient record system (related to diagnostic test results, electronic referral requests, and CPOE prescriptions) using a human factors engineering approach, and hence guide the development of interventions for work system redesign. Design This research will consist of multiple qualitative methods of task analysis to identify potential sources of error related to diagnostic test result alerts, electronic referral requests, and CPOE; this will be followed by a series of focus groups to identify barriers, facilitators, and suggestions for improving the electronic communication system. Transcripts from all task analyses and focus groups will be analyzed using methods adapted from grounded theory and content analysis.

Nurses prepare a summary of patient information that they consult and update throughout the shift. This document is believed to be integral to cognition, working memory, and decision-making. While serving as a key support to nursing practice, this summary also represents risks to patient safety. Characterized as a PCCAT, or Personally Created Cognitive Artifact, studies of this document in the context of nursing practice have not been reported. The absence of reported research, the importance of the document to nurse cognition and practice, and related safety risks prompted the research that this paper discusses. A taxonomy was developed through the analysis and coding of 151 PCCATs. Further analysis and mapping provided an ontology of the PCCAT. Content differences were noted between nursing units and among nurses. This may reflect differences in unit-based culture and/or differences in the patient complexity. The interaction between culture and perceived complexity of practice is one of the great difficulties in generating automated information systems for clinical practice settings. This paper is part of a larger research protocol that explores meta-level knowledge structures and revision to the understanding of the granularity of nursing knowledge. Development of a taxonomy and ontology of the nurse PCCAT, an important component of the larger research protocol, is described in this paper. [ABSTRACT FROM AUTHOR]

Cognitive artifacts--information displays that inform thought processes and increase knowledge--fulfill a fundamental role in distributed cognition. Cognitive work--the mental processes of selecting and evaluating data, reasoning, and making decisions--is guided and informed by cognitive artifacts, especially in clinical areas. The importance of cognitive artifacts to cognitive work suggests the need to study and comprehensively understand cognitive artifacts prepared and used by the clinical nurses and how these documents influence and guide nursing practice. This article identifies and describes the attributes of effectively constructed cognitive artifacts using the concept analysis process described by Walker and Avant.

Nurses prepare a summary of patient information that they consult and update throughout the shift. This document is believed to be integral to cognition, working memory, and decision-making. While serving as a key support to nursing practice, this summary also represents risks to patient safety. Characterized as a PCCAT, or Personally Created Cognitive Artifact, studies of this document in the context of nursing practice have not been reported. The absence of reported research, the importance of the document to nurse cognition and practice, and related safety risks prompted the research that this paper discusses. A taxonomy was developed through the analysis and coding of 151 PCCATs. Further analysis and mapping provided an ontology of the PCCAT. Content differences were noted between nursing units and among nurses. This may reflect differences in unit-based culture and/or differences in the patient complexity. The interaction between culture and perceived complexity of practice is one of the great difficulties in generating automated information systems for clinical practice settings. This paper is part of a larger research protocol that explores meta-level knowledge structures and revision to the understanding of the granularity of nursing knowledge. Development of a taxonomy and ontology of the nurse PCCAT, an important component of the larger research protocol, is described in this paper.

The "EMR Tutorial" is designed to be a bilingual online physician education environment about electronic medical records. After iterative assessment and redesign, the tutorial was tested in two groups: U.S. physicians and Mexican medical students. Split-plot ANOVA revealed significantly different pre-test scores in the two groups, significant cognitive gains for the two groups overall, and no significant difference in the gains made by the two groups. Users rated the module positively on a satisfaction questionnaire.

Six digital fundus cameras were examined to determine degrees of distortion introduced by lenses. Results quantified lens distortion effects on fundus images and demonstrate intrinsic properties in similar camera systems may vary.