Towards successful coordination of electronic health record based-referrals: a qualitative analysis

<p>Abstract</p> <p>Background</p> <p>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) (<it>i.e</it>., e-referrals), lapses in patient follow-up might occur. Although compelling reasons exist why referral coordination <it>should </it>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.</p> <p>Methods</p> <p>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.</p> <p>Results</p> <p>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 <it>shared </it>mental model to facilitate coordination and successful referral completion. Notably, very few barriers related to the EHR were reported.</p> <p>Conclusions</p> <p>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.</p

Factorial structure of the Chinese version of the 12-item General Health Questionnaire in adolescents

Aims. To evaluate the underlying factor structure of the Chinese version of General Health Questionnaire-12 using exploratory and confirmatory factor analyses in Chinese adolescents and find out which factor model proposed by previous empirical research is the best-fit model. Background. The 12-item General Health Questionnaire has been extensively used with adolescents in the West. Yet, it has not been used with adolescents in a Hong Kong Chinese context. Design. A cross-sectional study was employed. Method. Chinese students between the ages of 12-19 from four secondary schools were invited to participate in the study using the multiple-stage stratified random sampling method during the period from December 2007-February, 2008. The total sample size included in the final analysed was 1883. Results. The General Health Questionnaire-12 was found to be internally consistent. The results of exploratory factor analysis showed that there are two factors underlying the General Health Questionnaire-12. Of nine factor models were tested by means of confirmatory factor analysis, only three factor model: the eight-item two-factor model, 12-item three-factor model and 10-item two-factor model, demonstrated good model fit across all model fit indices. Conclusion. This study addressed a gap in the literature by evaluating the factorial structure of the Chinese version of General Health Questionnaire-12 using exploratory and confirmatory factor analyses in Chinese adolescents. The findings revealed that the eight-item two-factor model is the best-fit model. Relevance to clinical practice. The adolescent mental health problem is alarming and aggravating and warrants special attention. It is essential for community nurses to differentiate psychological distress in adolescents and to identify those adolescents who are at a higher risk of suffering from mental health problems. The availability of a valid and reliable instrument that measures adolescents' psychological distress is crucial before any nursing interventions to promote their mental health can be appropriately planned, implemented and evaluated. © 2009 Blackwell Publishing Ltd.postprin

The Multiple Sclerosis Genomic Map: Role of peripheral immune cells and resident microglia in susceptibility

We assembled and analyzed genetic data of 47,351 multiple sclerosis (MS) subjects and 68,284 control subjects and establish a reference map of the genetic architecture of MS that includes 200 autosomal susceptibility variants outside the major histocompatibility complex (MHC), one chromosome X variant, and 32 independent associations within the extended MHC. We used an ensemble of methods to prioritize up to 551 potentially associated MS susceptibility genes, that implicate multiple innate and adaptive pathways distributed across the cellular components of the immune system. Using expression profiles from purified human microglia, we do find enrichment for MS genes in these brain - resident immune cells. Thus, while MS is most likely initially triggered by perturbation of peripheral immune responses the functional responses of microglia and other brain cells are also altered and may have a role in targeting an autoimmune process to the central nervous system. One Sentence Summary: We report a detailed genetic and genomic map of multiple sclerosis, and describe the role of putatively affected genes in the peripheral immune system and brain resident microglia