Objectives: Poor outpatient referral communication is an important quality and safety issue. We implemented an electronic referral tool to analyze its impact on communication between primary care physicians (PCPs) and specialists. Methods: We studied one practice site that implemented the referral tool and one that did not and surveyed affiliated specialists, PCPs, and patients about referral communication. Results: Specialists more often received information before the referral visit from intervention PCPs versus nonintervention PCPs (62 percent vs. 12 percent, P <0.0001), a finding that persisted after adjustment (OR = 3.3, P = 0.008). Intervention PCPs more often received return communication from specialists (69 percent vs. 50 percent, P = 0.08), a finding of borderline statistical significance. Finally, patients of intervention PCPs were more likely than patients of control PCPs to report that specialists had received information before their visit (70 percent vs. 43 percent, P = 0.007). Conclusion: Referrals are a key outpatient transition of care. Facilitating transmission of referral information electronically can improve physician communication.

Introduction

Communicating patient information at the time of specialty referral is essential to high-quality consultation and coordinated, safe patient care. Both primary care and specialist physicians value this information exchange for shared patients,¹ but dissatisfaction with the current referral process is widespread among primary care physicians (PCPs) and their consultants.^{2, 3, 4} About half the time, the reason for dissatisfaction is a delayed or missing referral letter and reports. Other reasons include dissatisfaction with redundancies in the referral process, missing information in the referral communication, time required to write a referral note, and difficulty in finding a specialist.^{3, 4, 5, 6, 7, 8, 9} Studies have highlighted the problem of poor communication between PCPs and specialists in terms of timeliness and content. This represents a major opportunity for improvement.¹⁰

Strategies for improving communication of referral information have been proposed, including scheduling the specialist appointment from the referring physician’s office and providing pertinent information to the specialist, which have been shown to increase referral completion.² Specialists who received timely patient referral information reported providing optimal care twice as often as specialists who did not.¹¹ Other studies have looked at the benefits of physician training on how to write letters¹² and the value of form letters an d standard templates to improve letter quality from both PCPs and specialists.^{13, 14}

Few studies have examined the effects of electronic medical records (EMRs) on care coordination in general or on the referral process in particular.¹⁰ Computer access to chart notes was associated with increased communication between referring physicians and specialists, with specialists receiving written or e-mail referral letters more than twice as often as by telephone or other verbal communication.¹¹ Benefits of e-mail communication about referrals include the option for asynchronous communication, increased flexibility, and opportunities for back-and-forth interchange and enhanced rapport.¹⁵ To our knowledge, no controlled trial of electronic communication of referral information has been performed.

We hypothesized that electronic communication via a referrals tool embedded within an EMR has the potential to improve the timeliness and quality of referral communication and may also improve patients’ referral experiences. In this study, we used an electronic application, Referral Manager, within an ambulatory EMR, to optimize delivery of the referral and supporting patient information to the specialist. We then surveyed specialists, PCPs, and patients about their referral experiences.

Methods

Results

A total of 430 referrals made up the physician survey component of the study (261 interventions and 169 controls). Referral characteristics are shown in Table 1. Orthopedics and gastroenterology were the specialties referred to most often. Characteristics of the two participating practices and their patient populations for the specialist survey are also shown in Table 2. Of note, there were more PCPs and specialists in the intervention practice, and intervention patients were younger. Demographics of patient survey respondents are shown in Table 3; the control and intervention practices differed somewhat in terms of overall health and ethnicity/race.

Table 1

Types of referrals.

Table 2

Specialist survey practice and patient characteristics.

Table 3

Patient survey respondent demographics.

Response Rates

As shown in Table 4, the response rate for specialists was 55 percent (235/430). Of the 113 specialists who responded, 12 percent saw patients from both the control and intervention practices, accounting for 34 percent of survey responses (Table 2). The PCP response rate was 46 percent (54/117). The absolute response rate for the patient survey was 36.2 percent, although the participation rate after successful patient contact was 68 percent (143/210).

Table 4

Response rates.

Physician Surveys

Specialists seeing patients referred by intervention PCPs were significantly more likely than those seeing patients referred by control PCPs to have received information from the PCP prior to the referral visit (62 percent vs. 12 percent) (Table 5). When specialists did receive information, it contained all the necessary information in 93 percent of intervention referrals and 91 percent of control referrals. On multivariate analysis controlling for patient sex, insurance status, and intervention status, specialists were more likely to have received information on patients referred by intervention PCPs compared with control PCPs.

Table 5

Physician survey results.

Of the 83 control specialists who reported that they did not receive information, 20 percent felt that additional information would have been helpful. The additional information most often requested by control specialists was the problem to be addressed (53 percent), more patient history (41 percent), and question to be answered (35 percent). Intervention PCPs were more likely to receive communication back from the specialists (69 percent vs. 50 percent), although this finding was of borderline statistical significance (P = 0.08).

Patient Surveys

As summarized in Table 6, intervention patients were significantly more likely to report that specialists had received information prior to their visit (70 percent vs. 43 percent), and they heard information from their specialist that conflicted with their PCP significantly less often than did control patients (6 percent vs. 20 percent). There were also trends toward intervention patients reporting that the specialist was aware of the reason for the visit more often (76 percent vs. 60 percent) and rating specialist-PCP communication higher (58 percent vs. 43 percent) compared with control patients.

Table 6

Patient survey results.

Of the 30 patients who had returned to see the PCP by the time of the survey, 61 percent (14/23) of intervention patients reported that their PCP had heard back from their specialist compared to 43 percent (3/7) of control patients.

Discussion

We found that when PCPs used an electronic referral tool within an EMR, the chances that information would be communicated to specialists prior to the patient’s referral visit were three times as high as when PCPs did not use the tool. In addition, when the electronic referral tool was used, intervention patients were significantly more likely to report that specialists had received pertinent information prior to their visit and significantly less likely to have received conflicting information. There was also a trend towards intervention PCPs being more likely than control PCPs to receive information back from the specialists. These three findings strongly suggest that communication between PCPs and specialists was improved in our trial.

Our results also strongly suggest that the electronic referral tool was the source of the improved communication because the content of communication, once received, was equivalent between control and intervention practices. Therefore, the key to improving PCP-specialist referral communication is ensuring that communication occurs, rather than specifying the content of the communication. Our Referral Manager application helps ensure that communication occurs by allowing the PCP to specify the referred-to specialty and the reason for the referral and by automatically sending the referral question and supporting medical information in a timely fashion.

The intervention also tended to improve communication from the specialist back to the PCP, although this finding was of borderline statistical significance. While Referral Manager did not specifically address this return path of referral communication, this trend suggests that a specialist who receives communication is more likely to try to “return the favor” by initiating return communication. Such two-way communication is essential for clinical care, as poor communication is consistently a leading cause of medical errors.^{17, 18}

Only 20 percent of doctors who did not receive communication felt that it would have been helpful. This surprising finding may be explained by specialists’ lowered expectations for information from PCPs, a dysfunctional consequence of the culture of poor communication around referrals that our study seeks to redress. The benefits of the referral tool for referrals in this subset of specialists may have been large, as suggested by the fact that the information specialists sought involved required fields in Referral Manager, such as “the reason for the referral.” Our design of Referral Manager appears to provide the right balance of required and optional fields, thereby laying the foundation for future design of these kinds of tools in EMR systems.

Our referral tool also fits into clinicians’ workflow. This was evidenced by a referral tool adoption rate of greater than 99 percent at the intervention practice, according to the practice manager, even though its use was not required (data not shown). Perhaps in the future, use of this kind of tool for all referrals will help close some of the information gaps and improve tracking of referrals, while ensuring flexibility, since referrals to some specialties for routine care (e.g., ophthalmology) probably do not need the same level of detail. In the future, we plan to explore customizing the referral information according to the needs of different specialists.

Many patients could clearly identify when effective communication had occurred between their PCP and specialist; intervention patients were significantly more likely than control patients to report that the specialist had received prior information. Our data suggest that this realization might influence patients’ referral experiences, especially their ratings of the quality of PCP-specialist communication. Patients expect rapid communication between the specialist and the PCP, and they often have questions for the PCP that cannot be resolved if this communication has not occurred.⁴ These findings underscore the importance of improving communication to improve clinical quality and patient care experiences.

Widespread use of an electronic referral module could provide additional benefits. Electronic referrals can facilitate the inclusion of decision support into the referral process. For example, referring to cardiology for a coded diagnosis of new “atrial fibrillation” could trigger decision support suggesting that certain tests be ordered prior to the specialist appointment. In addition, systems could display clinical guidelines for certain common diagnoses, which might prevent unnecessary referrals. Practices also could track the reasons referrals are made to ensure standardization and appropriateness of referrals and to promote benchmarking and related quality improvement activities. To enhance the security of interprovider communications outside of a practice’s firewall, applications could create secure Web pages that could be accessed via e-mailed hyperlinks, thereby avoiding transmission of health information. Enhanced security of interprovider communications would be an integral component of a next-generation referral application.

The ability for PCPs and practice staff to track referrals is another potentially important benefit of an electronic referral module. As many as 20 percent of patients referred to specialists do not follow through with the visit.¹⁸ In one study of missed and delayed diagnoses in the ambulatory setting, 5 percent of cases involved the failure of a requested referral to occur, and 2 percent involved failure of the referred-to clinician to send results to the referring clinician.¹⁹ At one malpractice insurer, when looking at high-severity, missed-diagnosis malpractice claims, referral tracking issues came up in 55 percent of cases.^a A tool that allows PCPs and practice staff to electronically track referrals and be notified of no-shows could reduce some of the risk in the referral process. This aspect of our electronic referral tool could benefit from further study and evaluation.

Implementation of an electronic referral tool is challenging. It is critical to ensure that the application fits well into the workflow of the physicians and practices’ administrative staff. Usability is also important, and we consciously decided to limit the number of required fields to strike a balance between obtaining useful (coded and free-text) information, while not making data entry too onerous for the clinician. Adoption has been strong at the practice that has used the tool, and clinician response has been very positive. Plans are currently underway to implement the referral tool at other primary care practices in the system.

Limitations of this study include the potential for response bias, especially due to the difficulty in obtaining survey responses from PCPs. In addition, because of difficulties in contacting patients (especially controls, who were harder to reach), our patient survey numbers are low, limiting our ability to draw strong conclusions from this part of the study. We also do not have a good explanation for the difference in response rates between control and intervention patients, given that we attempted to contact them in the same manner. Finally, for logistic reasons, our study was not a randomized controlled trial or crossover trial. Although we tried to match the intervention practice with a similar type of practice (both community health centers that use the same EMR) and we controlled for differences in the primary outcome with multivariate analyses, unmeasured confounders could account for the differences we observed. Further studies with randomized controlled trials, using a larger sample, could be done to verify our results.

Conclusion

Referral communication is a critical, yet unevenly accomplished part of ambulatory care. Ensuring that this communication happens reliably is an essential component of the safe transition of patient care among providers. We found that an electronic referral tool improved communication from the PCP to the specialist. Further studies should be done to better understand adoption strategies and potential benefits of this technology.

Acknowledgements

This study was supported by a grant from the Commonwealth Fund. We acknowledge the contributions of Regina Breyt; Allyn Lodge; Pilar Conde; Julia Manasson; Sameer Bade, MD; Erica Featherstone; Carol Ireson, PhD, RN; Robert Hartley, MD; Michael Lambert, MD; and Elizabeth Scanlan RNC, NP.

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Footnotes

a

Personal communication from A. Puopolo, Harvard Risk Management Foundation Director of Loss Prevention, 2007.