Paper persistence, workarounds, and communication breakdowns in computerized consultation management

The consultation request process between primary care and specialty services often contains paper-based components that may be inefficient and difficult to track. Other barriers may include workarounds and communication breakdowns with the potential to adversely impact delivery of quality medical care. We investigated current challenges to the electronic outpatient consult management process in the United States Veterans Health Administration (VHA). Design: We conducted ethnographic observation and semi-structured interviews in nine different specialty clinics and three primary care clinics in a large, tertiary Veterans Affairs Medical Center (VAMC). We also performed a national-level query of 'electronic error and enhancement requests' (E3Rs) related to the consult package in the VA's electronic health record (EHR) submitted over a 5-year period (2005-2009). Measurements: Two researchers recorded the observable interactions and interview responses of 16 healthcare workers related to their work with consultations. Two separate coding schemes were applied to both the observational and the interview data. E3Rs from the national query were reviewed and categorized based on the nature of the enhancement requests. Results: We identified several examples of paper persistence, as well as workarounds, communication breakdowns, and redundancies in computerized consult management. An analysis of enhancement requests for the consults also revealed three broad needs related to reporting, configuration or customization, and user interface enhancements. Conclusion: Understanding these challenges to the current consult management process is important to help design enhanced informatics tools integrated into workflow to support coordination of care and tracking of consults requests.