| Overall perceptions |
“...our gut feeling was that it didn’t work. We’re always so nervous that something falls through the cracks, and we don’t know about it” (dermatologist). “...before the SmartPhrase the system was just based on messaging and it was just a lot of work for everyone. I think that things fell through the cracks as well there” (resident). “...a lot of backend work that I just don’t think is that efficient, because it’s never actually solving the problem. It’s like, we’re just kind of patching things up, patient by patient, making sure one person doesn’t falls through the cracks. But we’re just not able to account for everybody that way” (dermatologist).
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| Unclear roles and responsibilities |
“There’s so many residents, and we’re rotating so much, that you have to have a really well set up system that everyone’s involved in. Otherwise, things will for sure fall through the cracks” (resident). “...wasn’t honestly that clear whether it was the primary team that was sending the referral or whether we would send the referral [...] sometimes we were having the primary team send the referral. Then you would be reaching out to the medicine [admitting] team, like, ‘Hey, could you please put the referral?’ But I think just because I knew that I could send in the referral and it saves them a step, I would usually just do it anyway. I just felt like it was more work to have them do it. And I know they’re busy as well” (resident).
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| Multiple messaging channels |
“...sometimes residents would message through Epic® and then sometimes it would be through email. So, it wasn’t always consistent where these messages ‘lived.’ And then sometimes the messaging would actually take place in the referral itself. So, there were just so many different places for us to keep track of” (dermatologist). “...I look at my schedule an unhealthy number of times every day” (dermatologist). “...they are all small tasks but then when you’re seeing two to four or five new patients a day, and then discharging a similar number, it adds up, doing those messages and referrals and trying to keep track” (resident). “I would send the referral to, and then would send a staff message as well, to the front office staff...patient was admitted for this reason, we might follow up. I will try to specify the timeframe and if there was a specific provider. But I obviously wasn’t always including every detail that they might need to help set the appointment” (resident). “...it’s very important that when creating the referral...that the appointment is marked urgent. That’s the most important thing to make sure that the patients are scheduled in a timely manner” (scheduler).
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| Limited patient and caregiver input |
“...patients oftentimes have complex medical problems...the fact that they have a lot going on, it would be easy for them to not prioritize their skin issues” (resident). “...we need to ask the patient if they want an appointment because we actually were getting a bunch of patients scheduled, who then canceled same day or just no-showed, because they actually didn’t want follow-up. [...] it’s just very important to...engage the patient in that decision” (dermatologist).
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| Intensive patient tracking |
“...we probably micromanage it. We won’t let go until something’s happened. So I think that feeling of worry that something is going to fall through the cracks led us to all universally micromanage more and send a lot of messages, want to see the confirmation if a patient doesn’t show then go back and ask, and then resend referrals again, and have schedulers call” (dermatologist). “...sometimes patients are anticipated to be discharged and then the resident will send the message to the staff, put in the referral and then the patient ends up having another reason for the stay in the hospital longer than what we anticipated. So by the time the schedulers call, the patients are still admitted in the hospital and so they’re not able to appropriately gauge when would be a reasonable time to schedule the patient” (resident).
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