Memo
Reflections on In-depth interview 5/7/15
Research question: What is the current system for following up subcritical inpatient results?
Content of discussion. First question by interviewer gets at that main research question, but respondent starts talking about “the system that I need,” and describes the current state of how results are followed up, the pitfalls of the system, and where it is headed—seems to be a staged process of rolling out different interventions. Conversation covers impact of technology on this process, how that affects what is routine and what is ad hoc. Also the motivations of providers and their sense of role or responsibility, and how that impacts decision making, which also results in heterogeneous practices.
Types of interventions mentioned: d/c summary with area where providers fill in results to be followed up (not automatic); email process upon discharge from inpatient providers to PCP, also has a box to fill in, so relies on provider thinking of it, not being prompted; inpatient team taking on responsibility to follow up results that seem important to them (not a formal process, just happens). The idea of “workflow” mentioned a couple times, implying an automation or a routine, but not clear what this means. Late in interview, idea of “our workflow is x,” connecting the idea of workflow to an expectation, mentioned a “to-do list.”
Major themes/possible codes:
Impact of technology on the process. Respondent talked about current systems, which rely on the provider to think of which results might be pending and need follow up at the time of discharge. Described as “providers are queued.”… “not automatic”… “doesn’t feed forward,” but just having the box there does “jog the memory.” There was an implication about the fallibility of providers in thinking about this, or the idea of a threshold of urgency that compels the provider to act, “there are a subset of people for whom the inpatient provider feels compelled to actually page or call the primary care home staff or primary care provider”… this subset is small because of the “increasing reliance on electronic stuff.”--- not clear what this means, may refer to the d/c summary or email process, implies that that checks a box and makes the action of follow up by inpatient provider by page or phone call unnecessary. Discussion of how email is “populated,” (by provider, ?vs. being “automated”) and of “workflow,” and what is “built in” to LCR or “linked.” More doubt about ability of providers to consistently identify cases that require follow up in the absence of automation: “it not being automated means that it can get missed. It relies on people remembering what’s pending.” Mentions a specific thing that commonly needs f/u, a pulmonary nodule (this comes up as example again later).
Who is responsible for following up a test. The idea of conflict between the judgment of the inpatient and outpatient provider. “what is actually appropriate for the outpatient provider to work with.” Mentions responsibility, culture. The idea of the imperfect provider comes up again, “I’ve done my best to confirm….” [that the message has been passed on]: “it does some job, documenting that I’ve communicated.” Mentions relief of knowing that someone else is carrying the torch: “if people have a PCP, I’d feel better about it.” Wonders about where the inpatient and outpatient provider would find consensus, what is important to one vs the other, or what one thinks is indicated, though that idea is not overtly mentioned. “there are certain things that I would feel more likely that they would agree with.” Talks about “keep them a day longer,” the idea of keeping a patient in the hospital if there is uncertainty that a result will get followed up, begins to hint at what the risks are of the ball being dropped, that there is something so important about following up the result, that the person’s health depends on it so much, that even when a patient otherwise doesn’t need to be in the hospital, it’s worth keeping them to make sure it gets followed up. “I’d actually hold off on discharges.”
Technology replacing communication. Theme introduced by interviewer, “what proportion of your time do you actually have that conversation about primary, which is like who’s responsible for this.” Gets back to responsibility question, kind of ties the other two themes together—“most of the things I think are concerning enough….I still think it’s my responsibility.” But overall, inpatient provider “very infrequently” talks directly to outpatient provider, much more often communicates via email or through discharge summary.
What is a critical vs subcritical result. Blood cultures mentioned a couple times as a result that has the potential to become a critical result, pulmonary nodules mentioned as a less pressing issue. Idea that time is important “some of it has to do with how quickly it needs to be followed up”…. “there’s no way that in six months I’m still the one.” The idea of something “could turn into a critical thing.” “If it needs to be followed up within days, it’s on the inpatient person. If it needs to be followed within weeks, then it’s reasonable to expect the PCP to do it.”