In this study, we found that both PCPs and specialists at our institution were dissatisfied with the current referral process. We surveyed providers for general impressions of the referral process and with regard to specific referrals, and found issues of inadequate referral content and timeliness in both. The referral-specific data obtained by e-mail survey were remarkably congruent with the mail survey information. A key issue was the large discrepancy between what both groups of physicians thought was important information to convey and what they were actually communicating. In addition, key barriers to communication were identified, such as time to create an adequate note. Interestingly, patient factors and managed care insurance type were not associated with receipt of information, perhaps demonstrating that the problem is with the referral system as a whole. Like many other systems in medicine,12
this system was never consciously designed and leaves much to be desired. These data suggest that systems to improve the transfer of information from PCPs to specialists and vice versa could improve the quality and efficiency of care for patients that are referred.
Communication issues are important for physician satisfaction and for quality of care. Physicians making referrals have switched hospitals and specialists because of poor communication.13
In addition, physicians who received feedback were the most satisfied with communication from consultants and with the care their patients received.4
Finally, improving communication before referral visits occur can reduce inappropriate referrals.14
Thus, making the communication system more functional and precise could improve both physician satisfaction and the quality of care.
A critical component of effective referral communication is the referral letter. Both PCPs and specialists were dissatisfied with the content of the letters they provided each other and with the information they received. There were many items that specialists wanted to know that PCPs said they often did not include. This problem is not likely to be due to a lack of understanding about what is important to specialists, given the known consensus about note content previously demonstrated between generalists and specialists.5
Therefore, the lack of inclusion of important information is more likely due to time pressure. Both groups reported that the time required to create adequate notes was an important barrier. It has been shown that the quality of consultant reports increases directly with the amount of referral information originally received.15
Therefore, inadequate notes as perceived by both the PCPs and specialists in this study are likely to impact on the quality of the referral process. Interventions designed to streamline the referral process as a whole and to reduce the time required to create notes could improve the quality and content of notes.
Specialists were also dissatisfied with the timeliness of information they received, and 68% reported that they did not receive information before the referral visit. Therefore despite technological advances in communication (e.g., e-mail), we found that a large percentage of patients were referred without communication between providers. In addition, only approximately 25% of providers were using e-mail for referral communication. Not surprisingly, specialists who did not receive referral communication were significantly less likely to know what problems and issues caused the referral. Inadequate letter content and poor timeliness could account for the substantial percentage of specialists who did not have enough information to adequately address the problem. This in turn could lead to additional visits or redundant testing, and therefore increased costs. From the patient's perspective, the current system is hard to defend. Also, PCPs reported a 19% repeat referral rate due to problems not completely addressed at the first visit, some of which may be related to inadequate initial communication. Thus, both cost savings and better quality of care could result from improved referral note content and timeliness.
Similarly, PCPs were dissatisfied with the timeliness of communication. Four weeks after the referral visits, 25% of PCPs had not received information from specialists. Greater knowledge of consultation results could prevent time-consuming phone calls and could improve subsequent PCP-patient interactions. In one study, receipt of feedback from specialists was strongly related to communication by the PCP to the consultant at the time of referral. Referring physicians who personally contacted consultants or who supplied them with significant clinical information were more likely to learn the results of the consultation.4,8
This effect suggests that interventions to facilitate communication could have a major impact on the quality of the referral process.
In managed care environments, facilitating and improving the referral process is essential to maintaining the referral base of the organization and practicing cost-effective medicine. One study showed that communication between primary care and specialist physicians may be impaired when multiple health insurance plans with restricted panels of participating physicians are implemented in communities.16
In that study, physicians reported that for managed care patients, they were less likely to know the specialist, to speak personally with the specialist, or to send a written summary to the specialist. So-called integrated delivery systems have an obligation to invest in systematic communications programs to ensure proper flow of information between physicians and true integration.
One limitation of this study is that it was based at a single large tertiary care teaching and referral center. The problems faced by physicians at this site are likely very different from the challenges at smaller institutions. Both PCPs and specialists stated that system redundancy was an important problem. As referral processes become more complicated due to the complexity of health care plans and approval processes, medical centers of all sizes need to create systems that work smoothly and efficiently in order to minimize the clerical work of physicians. Large centers with more complicated referral patterns and administrative systems may find this especially challenging. A second potential limitation is respondent bias, particularly given our response rates. Physicians who were more dissatisfied may have been more likely to answer the survey. However, this still means that a large percentage of physicians in our system are clearly dissatisfied. It is unlikely that physicians who are poor communicators would have been more likely to respond to the surveys. Therefore, the issues of dissatisfaction and inadequate communication cannot be ignored.
In summary, communication between PCPs and specialists during the referral process is often inadequate both in terms of quality and timing, physicians are dissatisfied with the process, and physicians identify several important barriers to communication including time required to create adequate notes and redundant processes. Communication needs to be examined in greater detail to determine ways to improve it. Potential strategies include automating referral communication and letter generation through computerized referral applications. We are currently in the process of developing this kind of system. Future studies will examine whether improving communication can result in better patient outcomes, patient satisfaction, and resource utilization. Systems that can facilitate referral communication are likely to make the process more effective for both physicians and their patients.