Communication breakdown in the outpatient referral process

Abstract

OBJECTIVE:To evaluate primary care and specialist physicians' satisfaction with interphysician communication and to identify the major problems in the current referral process. DESIGN:Surveys were mailed to providers to determine satisfaction with the referral process; then patient-specific surveys were e-mailed to this group to obtain real-time referral information. SETTING: Academic tertiary care medical center.PARTICIPANTS: Attending-level primary care physicians (PCPs) and specialists. MEASUREMENTS AND MAIN RESULTS:The response rate for mail surveys for PCPs was 57% and for specialists was 51%. In the mail survey, 63% of PCPs and 35% of specialists were dissatisfied with the current referral process. Respondents felt that major problems with the current referral system were lack of timeliness of information and inadequate referral letter content. Information considered important by recipient groups was often not included in letters that were sent. The response rate for the referral specific e-mail surveys was 56% for PCPs and 53% for specialists. In this e-mail survey, 68% of specialists reported that they received no information from the PCP prior to specific referral visits, and 38% of these said that this information would have been helpful. In addition, four weeks after specific referral visits, 25% of PCPs had still not received any information from specialists. CONCLUSIONS:Substantial problems were present in the referral process. The major issues were physician dissatisfaction, lack of timeliness, and inadequate content of interphysician communication. Information obtained from the general survey and referral-specific survey was congruent. Efforts to improve the referral system could improve both physician satisfaction and quality of patient care. The referral process is a critical component of quality clinical care, and it has become increasingly scrutinized in the managed care era. Physician-to-physician communication is vital to the success of an outpatient referral. Optimal communication involves transfer of relevant clinical information in both directions (from the referring physician to the specialist and vice versa). Breakdowns in communication can lead to poor continuity of care, delayed diagnoses, polypharmacy, increased litigation risk, and unnecessary testing, 1 and can therefore decrease the quality of care.Difficulties with referrals are commonplace because of physician time constraints, lack of clarity about reasons for referrals, patient self-referrals, limitations imposed by managed care, and unclear follow-up plans. Several studies have shown that communication between primary care providers (PCPs) and specialists is suboptimal in many ways. In a 1983 study of inpatient consultation, 2 the requesting physician and the consultant completely disagreed on both the reason for consultation and the principal clinical issue in 14% of consultations. In one outpatient study done in 1980, PCPs only received followup information for 62% of consultations. 3 However, despite advances in medicine ...

Challenges in Referral Communication Between VHA Primary Care and Specialty Care

“…[1][2][3][4][5][6][7][8][9][10] Studies have found high rates of dissatisfaction with different aspects of primary-specialty communication-and specifically referral communication. 4,5 This problem is of increasing concern, as there have been recent national trends towards proportionally more primary care visits resulting in referrals to specialty care. 11 Optimal communication between primary and specialty providers is essential for realizing the goals of the patient-centered medical home (PCMH) care model, an increasingly dominant paradigm in primary care throughout the country.…”

Implementation Science Workshop: Implementation of an Electronic Referral System in a Large Academic Medical Center

“…45 Studies have shown increased physician satisfaction and better feedback from specialists when referral templates are used to standardize referral communication. 43,46,47 For instance, capturing the reason for consult is a key but often omitted step in the referral process, 13,[48][49][50][51] and thus electronic referrals must be designed to include a clearly defined justification of the referral. Furthermore, communicating details related to urgency is an important component of referral content.…”

“…10,11 At our institution, Brigham and Women's Hospital (BWH), the specialty referral process was problematic as well, with 63 % of PCPs indicating dissatisfaction with the procedures that were in place. 13 Long wait times for new visits to many specialties forced BWH PCPs to refer to non-BWH specialists. These non-BWH specialty visits increase fragmentation of care and hinder coordination of specialty care for our primary care population.…”

Innovation Opportunities in Critical Results Communication: Theoretical Concepts

“…While the primary onus of critical results communication in radiology has largely been placed on the interpreting radiologist, many communication failures are the result of lack of clinician availability or follow-up [4,22]. Current critical results communication models often rely on manual communication attempts to ensure that the critical results are successfully communicated, with frequent outsourcing of responsibilities to third parties.…”