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Hannah Nelson


A primary care EHR integration helped boost referrals, especially in settings with high clinician engagement.


EHR integration in primary care settings can increase referrals, but use of that health IT usually varies based on clinician engagement, according to a recent study published in the Annals of Family Medicine.

The study, which focused specifically on EHR integrations that help refer patients with hearing loss to audiologists, underscores the importance of clinician engagement in health IT use.

Primary care physicians (PCPs) rarely screen for hearing loss due to time constraints, conflicting priorities, and limited experience managing hearing loss, the study authors explained.

The researchers implemented an EHR integration at 10 clinics across two health systems to see if EHR prompts would boost PCP assessment of hearing loss.

The EHR implementation set off an EHR prompt to screen for hearing loss among patients ages 55 years or older, asking a validated one-question screener.

Overall, audiology referrals increased from 2.2 percent to 11.5 percent.

“This prompt may have reduced some of the uncertainty clinicians feel around hearing loss, thereby increasing their screening and referral rates,” the study authors suggested.

Through clinic observations and semistructured interviews with 27 family medicine clinicians, the study authors found several main themes.

First, the researchers noted that clinicians found the prompt overwhelmingly simple to use and considered it an effective way to increase conversations with patients about hearing loss.

“Our results indicated that the EHR prompt was easy to use and incorporate into typical workflows, likely because it was designed through extensive feedback from PCPs,” the study authors explained.

Next, the study revealed that clinician engagement and buy-in played a vital role in implementation of the health IT tool. For example, clinicians who shared personal experiences with hearing loss described strong support for the EHR integration, the study authors explained.

“They often emphasized the difficulty of addressing their own family members’ hearing loss due to an unwillingness to admit hearing loss or wear hearing aids,” the researchers wrote. “They viewed the prompt as an opportunity to discuss the impact of hearing loss on quality of life with patients.”

The research also revealed that medical assistant (MA) involvement in the EHR hearing loss prompt workflow varied by health system, clinic, and clinician.

Some physicians reported unclear expectations about how staff and clinicians should interact with the prompt. For instance, at one health system, MAs were responsible for addressing prompts related to colorectal and breast cancer screenings. The authors suggested that systematically leveraging MAs could be an effective way to increase the utilization of screening prompts in primary care.

“Moreover, expanding MA responsibilities may lead to innovations for panel management, health coaching, or patient navigation that reduce patient-level barriers to hearing loss,” the researchers added.

The researchers also found that clinicians prioritized the prompt during annual wellness exams compared to acute visits when there were more pressing health needs and concerns.

Lastly, while the prompt resulted in more conversations about hearing loss and more referrals, clinicians reported uncertain impact on patient outcomes.

“Clinicians were unsure whether the prompt had increased use of hearing aids, though most expected to see an increase over time,” the study authors wrote. “Many reported that additional barriers, particularly cost, would limit the number of patients who obtained hearing aids.”

“Longitudinal research is needed to know whether a prompt leads to improved hearing loss screening and referral over time,” the researchers noted.