"We Are Working Harder, Not Smarter": A Qualitative Inquiry into Care Coordination for Department of Veterans Affairs Mammograms Referred to the Community.

INTRODUCTION: The Department of Veterans Affairs (VA) relies on facilities outside of VA to provide mammograms for most VA patients. Prior work suggests challenges to coordinating some sex-specific services between VA and other health care systems (e.g., gynecologic malignancies, maternity care), but little is known about barriers and facilitators to mammogram care coordination. We sought to describe processes for coordinating mammograms referred outside of VA and to characterize VA staff perspectives on care coordination barriers and facilitators. METHODS: We conducted semistructured interviews with 44 VA staff at 10 VA Medical Centers that refer all mammograms outside of the VA. Respondents included staff across multiple VA departments involved in coordinating mammograms. We used a rapid templated approach to analyze audio-recorded interviews to characterize the coordination processes and identify barriers and facilitators to care coordination. RESULTS: Interviews elucidated a common mammogram care coordination process, with variability in how process steps were achieved. We identified six themes: 1) the process is generally perceived as inefficient, 2) clarity in VA staff roles and responsibilities is essential, 3) internal VA communication facilitates coordination, 4) challenges arise from variability in community provider processes and their limited understanding of VA processes, 5) coordination challenges can negatively impact veterans, and 6) technology holds promise but remains a barrier. CONCLUSIONS: Coordination of mammograms that are referred outside of VA is challenging for staff in multiple VA departments and roles. VA programs should focus on improving communication and role clarity within the VA and better harnessing technology to support coordination efforts.

Leveraging an electronic health record note template to standardize screening and testing for COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic challenged health care organizations to develop ways to provide patient care with rapidly changing guidelines and scarce resources. Clinical leaders and informatics specialists partnered to rapidly develop an electronic health record (EHR) template for primary care staff to screen Veterans at Veterans Affairs (VA) Puget Sound. The template prompts categorization of patients by stability and suspicion for COVID-19, and provides just-in-time triaging advice for clinic staff. Each category is a discrete data element and this information was used by leadership to track screening and testing volumes. We found that a brief, practical EHR note template can be quickly adopted to inform guideline-based screening, direct patient care, and conserve resources.

Expanding Primary Care Experiences With Novel Rotations for Residents at a VA Medical Center.

BACKGROUND: The number of graduating primary care physicians will not meet the demands of the growing and aging US population. In 2011, the Veterans Affairs (VA) Office of Academic Affiliations established 5 Centers of Excellence in Primary Care Education (CoEPCE) to transform primary care training. OBJECTIVE: We created an innovative training model with immersive primary care experiences to foster careers in primary care for residents. METHODS: As a CoEPCE, the Seattle VA partnered with the University of Washington internal medicine residency program to form a Center of Excellence (CoE) pathway with increased outpatient training time. The CoEPCE created a longitudinal curriculum of continuity clinic immersion and new thematically based rotations (eg, Homeless Health) for CoE residents. These rotations expanded primary care experiences and allowed for in-depth opportunities to care for the unique needs of veterans. Resident feedback was solicited through program evaluations, and career choices were tracked. RESULTS: Eighty-five of 102 (83%) possible rotation evaluations from 2014 to 2017 were reviewed. Residents reported that CoEPCE rotations had a positive effect on their care of patients and career choice, and provided opportunities to interface with faculty role models. Seventy-five percent of Seattle VA CoE residents selected primary care careers compared to 36% of historical controls. CONCLUSIONS: The CoEPCE rotation curriculum offers in-depth primary care training and may contribute to trainees maintaining interest in primary care careers.

Implementing an Opt-in eConsult Program at Seven Academic Medical Centers: a Qualitative Analysis of Primary Care Provider Experiences.

BACKGROUND: Electronic consultation (eConsult), which involves primary care provider (PCP)-to-specialist asynchronous consultation, is increasingly used in health care systems to streamline care and to improve patient access. The Association of American Medical Colleges (AAMC) formed a collaborative to support the implementation of an electronic medical record (EMR)-based, opt-in eConsult program across multiple academic medical centers (AMCs). In this model, PCPs can elect to send either an eConsult or a traditional referral. OBJECTIVE: We sought to understand the PCP experience with eConsult to identify facilitators of and barriers to the successful adoption of the model. DESIGN AND PARTICIPANTS: We conducted 35 semi-structured interviews and 6 focus groups with a range of primary care providers at 7 AMCs participating in the AAMC collaborative. APPROACH: Interviews were recorded and transcribed or detailed field notes were taken. We used the constant comparative method to identify recurring themes within and across sites, and resolve interpretive discrepancies. KEY RESULTS: We identified three major themes related to the eConsult program: (1) eConsult increases the comprehensiveness of primary care and fills PCPs' knowledge gaps through case-based learning. (2) Factors that influence PCPs to order an eConsult rather than a traditional referral include patient preference, case complexity, and need for expert guidance. (3) Implementation challenges included increasing PCPs' awareness of the program, addressing PCPs' concerns about increased workload, recruiting engaged specialist consultants, and ensuring high quality eConsult responses. Implementation success relied on PCP ownership of the consultation process, mitigating unintended consequences, ongoing education about the program, and mechanisms for providing feedback to clinicians. CONCLUSIONS: Our findings demonstrate that an opt-in eConsult program at AMCs has the potential to increase PCP knowledge and enhance the comprehensiveness of primary care. For these benefits to be realized, program implementation requires sustained efforts to overcome barriers to use and establish norms guiding eConsult communication.