Most PCPs and specialists in the United States communicate with each other through referral letters, without pre-visit consultation. In this study, we compared visit-based questionnaires filled out by specialists before and after the initiation of a novel electronic referral and consultation system (eReferral). eReferral facilitated communication between referring clinicians and a specialist reviewer prior to the appointment. We found that with paper-based referrals, specialists had difficulty identifying the clinical question. In surgical specialties, there was higher percentage of inappropriate referrals and need for unnecessary follow-up. The adoption of eReferral was associated with improvements in these. Differences were more pronounced for the surgical than for the medical subspecialty clinics.
For referrals made via eReferral, specialists reported higher rates of being able to determine the clinical question. Specialists’ difficulty understanding the consultative question provides insight into a failure of primary care-specialist collaboration. Despite its importance in providing effective specialty care4–6
and its impact on health outcomes13
, the frequency and quality of information exchanged between PCPs and specialists is often inadequate.4,9,18
One study examining PCP-specialist communication using paper-based referrals found that 24% of referrals did not include an explicit consultation question.3
With eReferral, the use of HIT facilitated iterative communication and allowed specialty reviewers to clarify the consultative question by requesting additional information prior to scheduling an appointment. The electronic system also ensured that referring information was available and legible at the appointment. Despite these improvements, in approximately 10% of eReferrals, the reason remained difficult to ascertain. This finding may reflect different standards as to what constitutes a clear consultative question or may represent that reviewers decided to schedule the patient for an appointment rather than attempt to further clarify the clinical question. Our data cannot distinguish between these possibilities.
We also found decreases in the proportion of referrals deemed to be inappropriate in surgical clinics. Our findings suggest that eReferral may be an effective way to prevent inappropriate referrals from resulting in appointments in surgical clinics, thus saving unproductive visits. In surgical clinics, after the adoption of eReferral fewer new appointments required follow-up visits and of those, fewer were deemed to be avoidable. The iterative pre-visit communication may be responsible for this observation. Prior studies have shown that direct communication with specialist consultants has the potential to decrease unnecessary visits. In one study, generalists felt that 33% of all referrals could have been avoided if they had training in simple procedures or been able to speak with a specialist.11
eReferral was designed to provide an alternative to formal consults for some cases.
eReferral changes the work flow of all involved: for referring providers, instead of handwriting a referral and handing it to a medical assistant for processing, he or she enters the electronic referral via the EHR. In a significant proportion of cases, the referring provider, upon receiving the reviewer’s response, must obtain additional history or tests prior to the appointment being scheduled. Sometimes the referring provider manages the problem without a specialty visit, with guidance via the eReferral specialist reviewer. In a complementary study completed by our research group, we found that PCPs reported that specialists offered better pre-referral guidance and addressed the clinical question more effectively with electronic referrals than with paper-based methods.2
While specialist reviewers were paid by a grant during the study, the hospital now compensates them for their time spent reviewing.
This study contained several limitations. Our study’s design relied on a comparison of responses before and after the initiation of a new system; the pre-post design limits our ability to determine causality. We determined the impact of eReferral on the referral process solely based on specialty clinicians’ perceptions, rather than objective criteria. However, given the clinical heterogeneity of the disease states being cared for across specialty clinics, the use of more clinically-detailed criteria was not feasible. The study included specialty clinicians with a broad range of clinical expertise and comfort in dealing with issues encountered in specialty care. Thus, their judgments may have been affected by their level of training. However, this level of training did not differ substantially before and after the intervention. It is possible that some specialty clinicians filled out questionnaires on more than one visit, but we could not adjust for clustering. We do not know the training level of referring clinicians, but we do not have reason to believe that proportions are different between paper-based referrals versus eReferrals. Non-response could have introduced bias. However, our response rates were over 70% and specialist clinicians were not aware of study aims or hypotheses. Our study has several strengths. We evaluated the initiation of a comprehensive use of Health IT in a complex safety-net system, rather than a pilot study among early adopters. We have included a diverse set of specialty clinics to expand generalizability. The referring clinics were also diverse, staffed by a wide range of health care providers from different disciplines and training background and different organizational structures. The uptake and use of eReferral by referring providers and specialists attests to the system’s perceived functionality and usability.24
Because the survey is encounter based, recall or response bias is less likely.
HIT, used in this manner, represents an important opportunity to improve PCP-specialist communication by facilitating communication prior to specialty appointments. In current specialty care practice, specialists share management roles with primary care physicians20
, but few models of shared care use computer-based systems effectively.19
Effective communication would not require electronic systems, but eReferral used computer technology to integrate referring provider’s requests with the EHR, to automate the routing of messages, and to send email reminders to referring providers. The delivery of high-quality specialty care requires clear and consistent communication between referring and specialty clinicians throughout the referral process.21
Lapses in communication result in iatrogenic complications, redundant testing and delayed diagnosis among other negative consequences in specialty care.4,6
An electronic referral system that allows a specialist reviewer to triage, clarify the consultative question, provide recommendations and to guide pre-visit evaluation can increase the appropriateness and effectiveness of specialty care.