Case Study: Harvard Risk Management – Paper vs Electronic Referral Letters

referral management software serviceElectronic Physician referrals and the Paperless Referral Discussion

Here is a great article that discusses the benefits of using a referral tool in combination with an Electronic Medical Records software platform. The article was written for a different study but its arguments for a paperless system still hold weight today.

Article: Referral tracking system | Online referral system – Learn more about referralMD’s healthcare software that handles referrals online.

We found that when PCPs used a physician 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 physician 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.

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.

Improve Communication Workflow

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.

Increased Referral Quality

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 inter provider communications outside of a practice’s firewall, applications could create secure Web pages that could be accessed via emailed hyperlinks, thereby avoiding transmission of health information. Enhanced security of inter provider 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.
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.

At one malpractice insurer, when looking at high-severity, missed-diagnosis malpractice claims, referral tracking issues came up in 55 percent of cases. 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 Personal communication from A.

Puopolo, Harvard Risk Management Foundation Director of Loss Prevention, 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.

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.

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