Barriers and Facilitators to Cross-Institutional Referrals: System Configuration Analysis of VA Staff Experiences
This study suggests system-level interventions are needed to enhance relationships between healthcare institutions, implement clearer policies for information exchange, and design better technologies that support efficient clinician communication. These findings have implications not just for VA healthcare but for any healthcare system that requires coordination between different institutions and providers.
College of Health researcher(s)
Abstract
Background
In 2014 and 2018, respectively, Congress passed the Veterans Access, Choice, and Accountability Act (Choice Act) and the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded eligibility for and use of cross-institutional referrals among U.S. Veterans enrolled in the Veterans Health Administration.
Objective
To identify facilitators and barriers to patient information sharing for cross-institutional, outpatient referrals resulting from policy changes.
Design
Applying the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 framework, we conducted work system and configural analyses of semi-structured interviews.
Participants
Clinical and administrative staff in six Department of Veterans Affairs (VA) facility community care liaison program offices.
Approach
Interviews focused on barriers and facilitators to sharing patients’ information across healthcare institutions. Transcripts were summarized by domain and coded to consensus, followed by directed content analysis and visualization using configural diagrams.
Key Results
From 19 interviews, we characterized a nine-step, ad hoc referral process. Barriers were reported in four of nine referral steps: scheduling, coordination, sending of pre-visit clinical records, and receipt of post-visit records. Low adoption of new technology, strained relationships with CCN clinicians, and inconsistent policies were commonly reported barriers. Largely, perceived barriers were classified as technology, people, or organization factors. The COVID-19 pandemic and a transition between third-party administrators were reported as notable environment factors.
Conclusions
VA staff perceived increases in patient care delays and staff workload associated with social and technical barriers to sharing patients’ information across healthcare institutions. In the cross-institutional referral process, we identified the primary configuration or combination of work system factors—technology, people, and organization— related to prevalent barriers. System-level interventions are needed to enhance relationships with clinicians across healthcare institutions, implement policies that guide patient information exchange, and design supportive technologies for efficient clinician communication during cross-institutional referrals.
Frequently Asked Questions: Cross-Institutional Referrals in the Veterans Health Administration
What prompted the expansion of cross-institutional referrals within the VA healthcare system?
The expansion of cross-institutional ("community care") referrals for Veterans enrolled in the VA was primarily driven by the Veterans Access, Choice, and Accountability Act of 2014 (Choice Act) and the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (MISSION Act). These legislative actions were a response to publicized issues regarding long wait times and limited access to care within VA facilities. The MISSION Act further broadened eligibility criteria, such as allowing Veterans residing more than 30 minutes from their nearest VA facility to access community care for primary services.
What are the main barriers hindering the effective sharing of patient information during cross-institutional referrals from the VA?
VA staff identified several key barriers to effective patient information sharing. These include: low adoption of new technologies like HealthShare Referral Manager by both VA and Community Care Network (CCN) clinicians, strained relationships and communication challenges with CCN clinicians (often due to issues like delayed reimbursements), inconsistent VA policies and procedures regarding referrals, and limited interoperability between VA's electronic health record (EHR) system and those used by CCN facilities, necessitating manual and time-consuming information exchange methods like faxing.
What are the primary facilitators that help streamline cross-institutional referrals for VA patients?
Despite the challenges, some facilitators were identified. These include the implementation of standard episodes of care (which define the scope of covered services), the VA's Referral Coordination Initiative (aimed at guiding Veterans through care options), instances where VA staff had access credentials to multiple EHR systems used by CCN clinicians (allowing direct information retrieval), and the increased adoption of telehealth services, particularly during the COVID-19 pandemic, which offered flexibility for both VA and CCN providers and patients.
How does the VA's community care referral process typically work, and at what stages are communication breakdowns most likely to occur?
The study outlined a nine-step referral process. The initial five steps are internal to the VA. Communication with CCN clinicians or staff begins around step six for appointment scheduling. Interviewees reported that steps 6B through 9, which involve ongoing communication and information exchange between the VA and CCN clinics (including scheduling, sending pre-visit records, the actual visit, and receiving post-visit records), are the most prone to communication breakdowns, leading to increased workload and delays.
How has the transition to new third-party administrators impacted the cross-institutional referral process?
The transition to new third-party administrators, responsible for managing the CCN in specific regions, was reported as a significant barrier. VA staff experienced issues with the accuracy of CCN clinician lists maintained by the new administrators and felt that the responsiveness to reported inaccuracies was insufficient. Additionally, some CCN clinicians were unaware of the changes or were hesitant to sign new contracts due to prior reimbursement issues. The new administrators also did not provide mechanisms for VA staff to report or track quality concerns regarding community care.
What role does technology play in the challenges and successes of cross-institutional referrals within the VA system?
Technology is a double-edged sword in this context. While tools like HealthShare Referral Manager were intended to facilitate information exchange, low adoption rates due to required training, software complexities, and frequent updates hindered their effectiveness. Limited interoperability between EHR systems forced reliance on inefficient methods like faxing. Conversely, when VA staff had access to CCN EHR systems, it significantly streamlined information flow. Telehealth also emerged as a positive technological factor, improving access and convenience.
How do organizational factors, such as VA policies and initiatives, influence cross-institutional referrals?
VA policies and initiatives, particularly those related to the MISSION Act, play a crucial role. While initiatives like the Referral Coordination Initiative and efforts to increase telehealth options were seen as facilitators in some cases, inconsistent implementation of policies, frequent changes without effective communication, and a lack of incentives for timely information sharing created barriers and confusion for both VA and CCN staff, as well as patients.
Based on the findings, what types of interventions are recommended to improve the cross-institutional referral process within the VA?
The study concludes that system-level interventions, taking a socio-technical approach, are necessary. Recommendations include focusing on building stronger relationships and communication channels with clinicians across healthcare institutions, establishing clear and consistent policies to guide patient information exchange, and designing user-friendly and interoperable technologies that support efficient communication and information sharing during cross-institutional referrals. Prioritizing the interconnectedness of technology, people, and organizational factors is crucial for effective improvements.