• Are Your Patient Referrals Getting Lost in the Shuffle?        

    AAFP Endorses Ambulatory Referral Guide

    January 30, 2018 12:40 pm Sheri Porter –    

    Every practicing family physician knows the frustration of setting up a patient consult with a subspecialist only to be left out of the information loop from that point forward. What many FPs probably don't realize is the extent of the problem nationwide.

    A new report released by the Institute for Healthcare Improvement and the National Patient Safety Foundation puts a number on those consults gone awry and offers a solution in the form of a nine-step, closed-loop electronic health record (EHR) referral process.

    The AAFP endorsed the 41-page report, titled "Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era," on Jan. 24.

    In its executive summary, the expert panel responsible for the guide's creation noted that more than 100 million subspecialist referrals are requested each year in ambulatory settings across the country, but only half of those referrals are completed.

    Panelists pointed out that incomplete referrals often are the result of process errors such as missing information and communication failures attributable to both primary care physicians and their subspecialist counterparts.


    • A new report released by the Institute for Healthcare Improvement and the National Patient Safety Foundation explores issues associated with ambulatory referrals.
    • The report notes that of the more than 100 million subspecialist referrals requested each year in the United States, only half are completed.
    • The report outlines a nine-step, closed-loop process for ensuring safer ambulatory referrals.

    "The goal of this report is to provide both technological and process-oriented recommendations to optimize the reliability of referrals in real-world clinical practice," wrote the authors.

    Panel co-chair Hardeep Singh, M.D., M.P.H., serves as a patient safety researcher at the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston.

    In an interview with AAFP News, Singh, an internist, said primary care physicians often refer their patients for tests, procedures and consultations; they are the physicians responsible for coordinating care and ensuring that the right information is in hand to make diagnoses and treatment decisions.

    "What's happening in the outpatient setting is a lot of breakdown," said Singh. "Our research shows that one in 20, or 5 percent, of U.S. adults will get a diagnostic error every year."

    "The primary care docs are not happy with the referrals and say specialists don't turn the information back. Specialists say, 'Oh, these primary care docs, they don't send us any information. I don't even know why I'm seeing this patient.'

    "And what happens is that the responsibility of care moves back and forth between the primary care physician and the specialist, and this is happening in a very fragmented outpatient environment," said Singh.

    Report Highlights

    The panel identified four general barriers to a well-functioning referral process that involve patient-centeredness, clinician and staff workload and workflow, accessibility and relevance of information, and communication and coordination between clinicians.

    The report then lays out seven principles that apply to all stakeholders, including physicians, the care team, EHR vendors, leaders of health care systems and, in some cases, patients and their families.

    Those overarching principles direct appropriate stakeholders to

    • design the referral process with the patient and family at the center;
    • create and communicate expectations, accountability and responsibility for adopting a closed-loop referral process;
    • implement consistent and coherent workflows;
    • minimize administrative burden;
    • employ user-centered design principles when creating or modifying EHRs for referrals;
    • ensure seamless information flow by addressing interoperability issues; and
    • measure the effectiveness and safety of the referral process.

    Lastly, the panel created a nine-step, closed-loop EHR referral process that follows this sequence:

    1. The primary care physician orders a referral.
    2. The primary care physician or a designated staff person communicates the referral to the subspecialist.
    3. The referral is reviewed and authorized.
    4. An appointment is scheduled.
    5. The consult appointment occurs.
    6. The subspecialist communicates the plan to the patient.
    7. The subspecialist communicates the plan to the primary care physician.
    8. The primary care physician acknowledges receipt of information from the subspecialist.
    9. The primary care physician communicates the plan to the patient and the family.

    The panel concluded that when gaps occur in the referral process they can "lead to preventable harm to patients and families, and increase providers' risk of allegations of malpractice."

    A Family Physician's Perspective

    AAFP Past-president Richard Roberts, M.D., J.D., a professor in the Department of Family Medicine at the University of Wisconsin School of Medicine & Public Health in Madison, served on the expert panel that created the guide.

    In an interview with AAFP News, he recognized the enormity of the project and applauded the group's efforts.

    "The issue of specialty referrals -- and tracking what happens with them -- is important to patients, certainly, and also is important to family physicians," said Roberts. "This endeavor is laudable because the aim is to clarify what that process is, better understand the steps involved, and as a result, hopefully better identify when it breaks down for us and for our patients."

    Roberts then put a family medicine twist on the topic.

    "If we want to get really good at referrals, fine. But I'd much rather get us better at boosting the capabilities of primary care so people don't get referred out so damned much."

    Roberts said it was a point he brought up early and often during the panel meeting, even though it wasn't popular.

    "I kept offering my view that referrals are necessary, but they should be used only when needed."

    As a family physician, Roberts does refer patients when necessary -- and he offered a very recent example of a referral process failure that could have been fatal.

    He told of a 20-something male patient who uncharacteristically showed up at a scheduled appointment with his parents in tow.

    The young man, whom Roberts had cared for since toddlerhood, said he was struggling with drugs and alcohol -- not a good mix for someone who had lived with anger, anxiety and depression issues for years -- and Roberts knew a consultation for addiction and mental health intervention services was needed.

    "We gave him all the info to make it happen three weeks ago," said Roberts, but the patient never followed through and ended up in the hospital with serious injuries following a high-speed rollover accident.

    "It's bad enough that my patient went three weeks without making the contact he had been advised to make even after we wrote the number down for him," said Roberts.

    "However, the greater frustration was that he was expected to call the consultants, when the requested referrals were both with the same health care system. It would have been far better if we could have booked the appointments at the moment the decision to refer was made."

    Unfortunately, said Roberts, the addiction and mental health professionals urge physicians to have the patient make the phone call because it increases the patient's commitment to follow through and show up at the appointment.

    Roberts used the story as an example of the difficulties in closing the referral loop in primary care and why the recently released guide could prove useful to family physicians and their patients.

    "If only there had been a way to more effectively prompt me and the patient, and most importantly, the consultants whose services he needed. This patient needed more help than I was able to offer him, and that's where consultation is always a good idea." said Roberts. "It didn't happen in this case, and it should have."

    Get Started Now

    Singh identified some steps physicians can take right now to begin to implement a closed-loop patient referral process in their practices.

    To start, he suggested physicians measure some of their own referral process outcomes using data they already have.

    "Let's say I sent 35 consults out in September. If I do an audit in November or December and I find that eight consults are still incomplete, that's an eye-opener," said Singh.

    "This is an opportunity for improvement. Find out what referrals have not been closed and then figure out why they aren't closed." It could be as simple as a missing piece of information that the consulting physician is waiting on, he added.

    When it comes to EHR solutions, Singh suggested that physicians may have more power than they realize. He noted that EHR vendors tell him that demands from physicians and health care institutions for EHR software changes can prompt action.

    In addition, robust HHS oversight has raised concerns with EHR vendors and made them more amenable to listening to their customers.

    "There are certain basic things all EHRs should do," said Singh. For instance, does your EHR

    • auto-populate patient details into the referral template,
    • offer a space in the referral template to enter the reason for the referral, and
    • have a place to indicate the urgency of the referral?

    "Referral templates should include these properties, and people should demand them," Singh stated.