Browsing by Author "Sangani, Amee"

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    50048 Closing the cross-institutional referral loop: Assessment of consultation note quality
    (Cambridge University Press, 2021-03-30) Savoy, April; Sangani, Amee; Weiner, Michael; Medicine, School of Medicine
    IMPACT: Results will inform the design of health information technologies that assess and improve clinicians’ interpersonal communication supporting co-management of care across health institutions. OBJECTIVES/GOALS: Poor communication and co-management of comorbidities during the referral process increase physician workload, patient burden, and safety risks. In this preliminary study, our objective was to understand how consultants’ notes support physician collaboration within and across health care institutions. METHODS/STUDY POPULATION: We reviewed medical records. Accessing the Indiana Network for Patient Care database, consultation notes were randomly selected from four specialties: cardiothoracic surgery, neurology, rheumatology, and oncology. These specialties were identified, in advance, as challenging in interprofessional communication. The notes reviewed were associated with in-person consultations at a medical network in the Midwest from 2016 to 2019, including internal and cross-institutional (i.e., external) referrals. The Quality of Consult Assessment tool was adapted to assess note quality and co-management facilitation. Two researchers reviewed all records independently. A consensus meeting was then held to discuss and resolve discrepancies. RESULTS/ANTICIPATED RESULTS: Medical records of ten patients with comorbidities were reviewed. The mean age was 67 (SD= 12 years); one patient was a child. All consultation notes contained clinical recommendations. Seventy percent of notes referred to explicit consultant responsibilities. Conversely, only one contained explicit responsibilities for referrers. Medical records denoted reliance on support staff to send messages among referrers, consultants, and patients via phone calls and facsimile. The use of fax machines to send medical records to referrers was more prominent after cross-institutional consultations. DISCUSSION/SIGNIFICANCE OF FINDINGS: Clinical documentation supported specialty referrals for transitions of care rather than co-management of care. Accessing medical records across institutions contributed to a lack of clinical context, and workflow inefficiencies, when attempting to co-manage clinical care.
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    Characterizing barriers to closing cross-institutional referral loops: Workflow and information flow analysis
    (Elsevier, 2024) McCormack, Cassandra; Savoy, April; Mathew, Anna; Marcum Gilmore, Alexis; Cottingham, Elizabeth; Sangani, Amee; Caldwell, Barrett; Holden, Richard J.; Weiner, Michael; Medicine, School of Medicine
    The specialty referral process consists of primary care clinicians referring patients to specialty consultants. This care transition requires effective care coordination and health information exchange between care teams; however, breakdowns in workflow and information flow impede "closing the referral loop" and delay or prevent referrers from receiving the consultant's "visit notes," particularly in cross-institutional referrals. This study aimed to describe and map the referral process as it occurs in clinics and identify and characterize work system barriers affecting its performance. Referrers and consultants were interviewed about their perceived workflows, barriers, and clinical outcomes to inform a workflow analysis.
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    Consultants’ and referrers’ perceived barriers to closing the cross-institutional referral loop, and perceived impact on clinical care
    (Elsevier, 2023) Savoy, April; Khazvand, Shirin; Mathew, Anna; Marcum Gilmore, Alexis; Cottingham, Elizabeth; Sangani, Amee; Weiner, Michael; Damush, Teresa M.; Medicine, School of Medicine
    Background: Cross-institutional (external) referrals are prone to communication breakdowns, increasing patient safety risks, clinician burnout, and healthcare costs. To close these external referral loops, referring primary care physicians (PCPs) need to receive patient information from consultants at different healthcare institutions. Although existing studies investigated the early phases of external referral loops, we lack sufficient knowledge about the closing phases of these loops. This knowledge could allow health care institutions to improve care coordination and rates of closed referral loops by implementing socio-technical interventions for patient information exchange throughout a referral loop. Human factors engineering (HFE) provides a systematic approach to advance our understanding of barriers perceived by physicians. Using HFE, our objective was to characterize referring and consulting physicians' barriers to closing referral loops and implications for care. Methods: This qualitative cross-sectional study included semi-structured interviews with referrers and external consultants. We used the Systems Engineering Initiative for Patient Safety 2.0 framework to conduct rapid qualitative analyses, determining perceived barriers and related implications. Main measures were consultants' and referrers' perceptions of, and experiences with, barriers to external referrals. Results: Six referring PCPs and 12 consultants participated from two healthcare systems and four medical specialties. Physicians perceived three main barriers in external referrals: receipt of excessive and unnecessary faxed documents, missing or delayed documentation, and organizational policies regarding information privacy interfering with closing the loop. Compared to internal referrals, physicians reported increased staff burden, patient frustration, and delays in diagnosis with external referrals. Consultants reported the ability to provide the same level of care to patients with internal or external referrals. However, consultants described communication breakdowns that prohibited confirmation of follow-up plan retrieval, initiation, or effectiveness. Conclusion: Physicians reported technological and organizational barriers to closing cross-institutional referral loops. Promises of HIE technology for external referrals have not fully materialized. Among physicians and patients, retrieval and exchange of medical information increases perceived workload, burden, and frustration. These increases are not accurately captured by traditional organizational metrics. This study provides evidence that informs future human factors engineering research to address perceived barriers and guide future HIE design or implementation.
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    Evaluation of Consultation Notes Within and Across Institutions: A Preliminary Study
    (Indiana University Medical Student Program for Research and Scholarship, 2020) Sangani, Amee; Savoy, April; Medicine, School of Medicine
    Background/Objective: Patients with multiple chronic conditions require specialty consultations both within and across institutions for effective co-management of comorbidities. Poor communication during the referral process increases physician workload, patient burden and risks. Successful co-management relies on bi-directional information flow that supports interpersonal communication and establishment of clear tasks and responsibilities among physicians. However, flow of health information is often limited to specific health network access, phone calls, or faxes. Interpersonal communication is dependent on limited encounter notes. In this preliminary study, our objective was to understand how consultants’ notes support physician collaboration within and across health care institutions. Project Methods: To assess consultants’ notes, outpatient charts were randomly selected from the Indiana Network for Patient Care database representing consultations with five different specialties within the IU Health network, including referrals from within and outside of IU Health. The Quality of Consult Assessment tool was adapted to assess content of notes, emphasizing clinical recommendations, distribution of tasks and responsibilities, and communication plans. Results: Our sample included ten charts for patients who had comorbidities. All notes contained clinical recommendations that included an assessment and plan. 70% of notes contained explicit responsibilities of the consultants. Conversely, only one contained explicit responsibilities for referrers. Charts denoted reliance on support staff to send messages between referrers, consultants, and patients via phone and fax. Phone calls and faxes were more prominent in referrals across institutions. Conclusion and Impact: Our preliminary findings indicate that current clinical documentation supports specialty referrals for transitions of care rather than co-management of care. Difficulties in accessing patient charts across institutions leads to a lack of clinical context and workflow inefficiencies when attempting to co-manage care. These findings demonstrate negative implications in health outcomes for patients with multiple comorbidities that require more care coordination within and across institutions.