When I worked as a primary care physician, referrals were a great concern of mine. Even though electronic medical records were in use, I had no way of knowing that a referral had taken place unless I proactively followed up.
My personal solution was as low-tech as they come: I used sticky notes to keep tabs on what I considered critical referrals — a patient with a breast lump referred to a surgeon for evaluation, for example. I stuck the notes in a folder and referred to them periodically so I’d remember to check the patient’s medical record and make sure the appointment had been scheduled, the specialist’s notes were available, or a plan of care was in place. I emphasize this was my system; I had no idea what other PCPs in the practice did to keep track of their referrals. There simply was no standard.
Why is this so important? Because a referral that falls through the cracks can lead to significant delays in sometimes critical diagnoses and subsequent delays in treatment.
Unfortunately, referral processes are too often problematic, and we need to change that. Patient referrals in ambulatory settings are on the rise in the US, having increased from 40.6 million in 1999 to 105 million in 2009. With that volume of activity, there is tremendous risk of harm when details get lost or miscommunicated within faulty systems.
IHI, in partnership with CRICO/Risk Management Foundation of the Harvard Medical Institutions, recently convened a panel of subject matter experts to evaluate what can go wrong in the referral process and develop recommendations for improving it. The outcome of this work is a range of recommendations for making the referral process more efficient, effective, and painless for clinicians and patients alike.
Closing the Loop
Our panel found that current referral practices are vulnerable owing to a lack of standard protocols, ambiguous roles and responsibilities, shortage of staff to monitor the process, and a lack of clear policies and instructions. (For example, what should be done if a patient does not show up for an appointment?) Every step in the process — from ordering the referral to communicating the plan of care to the patient and family — offers a risk of a breakdown.
These gaps in the referral process can lead to missed or delayed diagnosis and delayed treatment. A 2013 study found that breakdowns in the referral process occurred in 20 percent of diagnostic errors in primary care. When malpractice claims are made in the ambulatory setting, almost half involve a failure to follow up, many of these related to specialist referrals, according to CRICO.
Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era outlines a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels and in a timely manner. The recommendations in the report address each of the steps and suggest actions for clinicians, leaders of health care organizations, and EHR vendors.
Some of these recommendations require improving interoperability of EHR systems, but many of the steps outlined can be put into practice with existing technology and without adding to the administrative burden of clinicians.
For example, clinicians within a practice can begin by developing a standard protocol for ordering referrals, ensuring all relevant information is available to the specialist, setting definitions for urgency, and specifying the urgency with every referral. Clinicians can improve the process simply by being more clear and direct in communicating to patients about what they should expect and the timeline for the referral.
The most important lesson to take from this work is that health IT on its own cannot fix the referral process. In some cases, the use of EHRs can bring new risks. We absolutely need to improve the current technology for managing referrals, but equally important is having standard processes by which all clinicians in a practice make and track referrals and optimize communication with other clinicians and with the patient.
While it may take a while to achieve a fully functional closed-loop process, there are things we can do today to start this work. And by engaging all stakeholders, we can eventually achieve a much more robust process.