Specialty medical care is vital for our primary-care patients and, except for self-referrals, outpatient specialty care does not typically occur unless referrals are processed and completed without error. Although lack of timeliness is a major problem with current referral systems13
, and delays in completion of consultation are associated with adverse clinical outcomes14
, hardly any studies have systematically evaluated the impact of scheduling systems on outcomes in a healthcare setting. In this study, we designed and implemented a Web-based system, shared by generalists and specialists, for scheduling outpatient consultation. Independent of other measured factors, including temporal changes in referrals, the referrals with ROMP were at least twice as likely to have a scheduled visit, compared to those without ROMP. Without a systematic, partly automated approach, the referrals, which often occur via fax, can be lost through mishandling or even just fax machines that run out of paper. Furthermore, such errors can be difficult to track or even identify quickly. Our system improves care by adding a shared information and communications system as well as automated alerts about referrals that have not been addressed promptly.
Better coordination of referral could improve efficiency, costs, and quality of care. Various approaches have been taken to address the problems of referral. The Department of Veterans Affairs initiated a Quality Improvement Technical Assistance Project specifically to address the completion of consultations15
. Some have reported electronic messaging systems between primary and secondary care16
. The Walter Reed Army Medical Center implemented an “Ask a Doc” referral system based on electronic mail, with an average response time to consultation of less than one day17
. Additional work in this field could determine which features of such systems are most important and whether combining features improves outcomes.
Benefits of a computer-based referrals system, such as described here, could well be seen in other settings. The local system used the Web and a standard Web browser, without directly requiring an electronic medical records system. The system created the methods and capacity to record and deliver clinical history and the reason for the referral. Although we did not study and report about usability, we observed that the system was highly usable and valued by both staff and providers. It fit well into workflow, since referrals staff had desktop computers and could spend blocks of time using the computer interface to process referrals in batches. The time required to process a referral was not measured but was estimated to have decreased, due to the way the intervention eliminated problems with lost faxes and needs to interrupt workflow with duplicate fax transmissions and telephone calls to track paperwork. A more detailed assessment of usability would require further study.
With attention to design, systems of this type could more effectively address common reasons for denied referrals, such as duplicates, inadequate clinical criteria, or an incorrectly targeted clinic site. This can ultimately reduce waiting times and efficiency or accuracy of billing18
. One radiology study comparing online scheduling to traditional telephone-based scheduling showed that 78% of physicians felt ready for online scheduling, and 75% of physicians who tried the system stated that it was easier to schedule patient online19
. Another radiology study showed that patients’ waiting times decreased from two or three weeks for telephone-based scheduling, to two or three days for electronic scheduling20
In the analysis with the longer interval, single orders and older ages were independently more likely to lead to scheduled visits. Coordinating referrals for patients who are hospitalized, institutionalized elsewhere, or require frequent medical care may be difficult and require multiple referrals, and this may explain the lower scheduling rates for those with multiple referral orders. With the methods of this study, we cannot ascertain why older patients were somewhat more likely to have scheduled appointments. Their greater comorbidity may translate to more urgent clinical needs, or their insurance coverage—more universal with Medicare—may have played a role.
Some referrals did not seem to benefit from the intervention. Referrals for continence or rehabilitation saw a decrease or only a modest increase in scheduling. Although we did not investigate these specific cases, we suspect special circumstances unrelated to the intervention but that could not be overcome by the intervention. The intervention, for example, cannot address the problems of full clinics or other backlogs or idiosyncrasies in the workflow of processing referrals. The intervention seemed to address only the most common causes of lost or delayed referrals.
The study has limitations. Since staff at consulting sites managed both faxed and Web-based referrals, contamination may have occurred if experience with the intervention led to closer follow-up of controls, but this would provide us with a conservative estimate of the intervention’s effect. This analysis also did not examine kept visits, which would ultimately be important in assessing completion of consultation, but the intervention was meant to target scheduling, rather than aspects of consultation more related to patients’ own behaviors. Attenuation of effect may be seen with a longer follow-up period.
In conclusion, with a Web-based referrals and scheduling system, referrals were nearly three times more likely to lead to a scheduled visit, after adjustment for other factors. Especially in a country with such a large supply of specialists, access to specialty care should not be hindered to such a large degree by the type of preventable error studied here. Although health information technology cannot solve all issues in our clinics, it can nearly eradicate the problem of failed scheduling. Nevertheless, even with computer-based approaches, scheduling systems can be better. An ideal system will have clinicians providing the key clinical pieces while other office staff handle key administrative elements. Further integrating referrals with a more robust clinical decision support system could lead to more appropriate referrals and fewer denials. Thus, to optimize clinical care, we’ll need systems that do a better job of bringing together not only generalists and specialists, but clinicians and office staff, so that each role is effectively and efficiently served by those with the skills and expertise to match.