Electronically transmitted referrals have the potential to improve patient follow-up because they ensure delivery of information and can be tracked, in contrast with paper-based referrals. We found that over a third of referrals were initially discontinued and returned to the PCP by the subspecialists; however, timely follow-up actions (scheduling future subspecialty appointments) still resulted in about half of these cases. In the majority of cases without timely follow-up, subspecialists most often cited lack of prerequisite testing by the PCP and no necessity for subspecialist intervention as reasons for discontinuation of referrals. However, in over 15% of discontinued referrals, we did not find any explanation for the lack of follow-up by the subspecialist within 30 days of referral transmission. Extrapolating from our sample to the entire population of the referrals we extracted, we estimated that this scenario occurred in about 6% of all referrals. Meanwhile, approximately 7% of discontinued referrals received no further follow-up from PCPs. Our study thus reveals that breakdowns in referral communication might occur even when referrals are transmitted through an integrated EHR.
Although 474 referral requests in our study appeared to have no documented response from a subspecialist, these represented a relatively small proportion of referrals overall. Of greater concern is the relatively large percentage of discontinued referral requests that required additional follow-up action from the PCP where no action was documented. Documentation and execution of necessary next steps in the referral process represent vulnerabilities for timely patient follow-up and safe patient care. Our findings suggest there is ample room for improving the electronic referral communication process, which may in turn reduce delays in care and potential harm. To our knowledge, this is the first study to evaluate timeliness of follow-up of referral communication through an integrated EHR.
Improving the outpatient referral process poses several challenges. In discontinuing referrals subspecialists stated justifications, such as lack of prerequisite workup, which suggest possible disagreement on criteria for referral to their services. This is consistent with a previous study of communication breakdowns in which subspecialists and PCPs did not consistently agree about the reasons for referrals24
. In a few cases, subspecialists did not believe sufficient information was provided in the referral to make an informed decision. Both quality and quantity of information provided in referrals need further study; a recent study found that more than one in four referrals did not contain a clear clinical question25
. Future work may need to focus on developing, adopting, and integrating referral criteria specific to the services receiving referrals and testing EHR-based referral templates that reflect such criteria.
It was also concerning that 7.4% of discontinued referrals that required follow-up actions by the PCPs did not always lead to timely response. Given the large volume of discontinued referrals, we believe this to be of great significance. In the VA system, practitioners have the option of turning off certain referral-related notifications, including those alerting them about referral discontinuation. Although we were unable to track whether the practitioners involved had indeed turned off referral notifications, our previous work has shown that certain high-priority notifications might still be overlooked within the EHR despite the notification receipt21,22
. Thus, our work establishes the need for reliable systems-based tracking procedures to identify communication breakdowns related to electronic referrals.
Based on our findings we propose several potential strategies to improve the referral communication process and lay the foundation for future research. First, in order to develop system-based interventions in this area, a better understanding of variation in referral communication processes and policies across settings and subspecialty services is needed. For instance, responsibilities of PCPs and subspecialists should be better defined in the context of referrals and key processes and best practices should be shared and standardized across subspecialty services, when possible. Potential interventions to reduce discontinuations include clear referral criteria, developed with input from both PCPs and subspecialists, clarifying which patients are “eligible” for referrals. Second, effective procedures to ensure appropriate follow-up of unresolved or discontinued referrals in institutions using integrated EHRs must be established. For instance, implementation of a system to track referrals could perhaps prompt a non-provider when referral information has not been acted upon in a defined time period. Third, ensuring that PCPs provide adequate information to the subspecialist, perhaps through EHR-based referral templates17,26
, will minimize the risk for discontinuation of the request and reduce valuable subspecialist time spent on redundant chart reviews. Although this may not be an easy goal to achieve, automated information extraction tools that populate the electronic referral template could ease the burden of completing a detailed referral template26
. Finally, PCPs must state a clear referral question to avoid ambiguity about the need for referral, and EHR systems should provide a distinct mechanism for this, perhaps including a list of generic referral questions (e.g., “Does this patient need X procedure?” or “Can you help adjust X medication?”).
Our study has several limitations. We sampled from a single institution and focused on outpatient referrals to a specific set of subspecialties. Our findings thus may not easily generalize to other sites or subspecialties or to the inpatient setting. Nevertheless, they provide significant safety insights for health care systems where subspecialist access may be capped and provide valuable lessons on EHR-based referral communication that may be applicable to other settings. We also did not include any direct comparative evaluation with a paper-based system. While such a comparison would have certainly provided valuable findings, communication processes in a sample size of comparable magnitude would be much harder to track in paper-based referrals. Additionally, communication breakdowns related to referrals have already been described in paper-based systems3–5
. Although we relied on medical record review data for certain implicit clinical judgments, we used consensus to reduce bias. We also used an arbitrary time period of 30 days to determine follow-up actions by subspecialists. However, currently there are no accepted standards on timeliness or what constitutes a delay in referral communication except those suggested by the VA, consequently our work could lead to future knowledge generation in this area. Lastly, we did not measure actual harm from delays in referral care. The mean potential harm scores in our study were overall low, suggesting that harm was unlikely or minimal from many of these delays, even though some patients may have been at risk for significant harm.
In conclusion, we found that an EHR facilitated a valuable interchange of information at the PCP-subspecialist interface; however, unexplained lack of follow-up on communicated information by both PCPs and subspecialists persisted in a subset of cases. To improve the timeliness and efficiency of the referral process, future research and interventions should aim to standardize referral communication processes, design effective referral tracking mechanisms, and develop and adopt strategies to reduce the potential for communication breakdowns.