Outpatient referrals, defined as processes that include a transfer of responsibility for some aspect of patient’s care from a referring provider to a secondary service or provider, [1
] are an important but challenging aspect of primary care practice. Successful coordination of referrals hinges upon effective and timely communication to facilitate information sharing and transfer of patient care responsibilities between outpatient providers [2
]. However, referral communication related to both provider-provider and provider-patient interactions [3
] is prone to breakdown [2
]. The growing use of referral care [23
] suggests the need for improving reliability and efficiency of the referral process to create a greater impact on health care quality.
In accordance with the 2009 Health Information Technology for Economic and Clinical Health Act (HITECH) and its Meaningful Use goals for effective use of electronic health records (EHRs), healthcare institutions are increasingly adopting technology to support patient care. By 2015, hospitals are expected to demonstrate, among other things, the capability to exchange key clinical information among providers of care and other patient-authorized entities electronically [24
]. This increasing adoption of health information technology holds promise for improving referral communication in health care [25
]. However, early adopters of these technologies, mostly large integrated systems, have encountered novel communication challenges and unintended consequences that are important to understand in order to reduce future care delays [18
Many referrals between primary care providers (PCPs) and specialists do not take place within the same practice or institution; and in general, providers don’t have access to the same EHR. However, efforts to address communication challenges using EHRs will be essential given the emphasis on coordination of care and exchange of relevant clinical information by the Patient Protection and Affordable Care Act of 2010 [36
]. Recent reform initiatives call for healthcare institutions to become Accountable Care Organizations (ACOs) [37
] and demonstrate the use of evidence-based medicine and the application of evolving technologies to support a strong foundation for coordinated primary care. They also create an expectation of continuous process improvement based on measurement of clinical quality and outcomes [38
]. EHR-based referrals thus would be an essential component of patient care through ACOs. Even when supported by technology, referral communication between PCPs and specialists is often unsatisfactory [39
]. This might be partially due to lack of attention on how communication technology fits with the social environment in which it is implemented [40
]. Addressing these key challenges in making electronic referral communication effective [11
] requires a multifaceted “socio-technical” approach [43
Although efforts have been made to improve and standardize overall EHR usability, [44
] there are presently no standards that specifically address the design or use of electronic systems in outpatient referral communication, and best practices in this area are limited [6
]. In fact, no available turn-key EHR system can fully support the complexities of most referral processes. Furthermore, referral processes are highly variable across health care settings, and EHRs that support referrals are often heavily customized to reflect unique organizational requirements [19
]. Although complete standardization of referral practices is neither possible nor desirable, several aspects of referral communication are amenable to strategies to reduce the risk of unintended consequences and delays in patient care.
This article describes ten recommendations that represent potential best practices to design, develop, implement, improve, and monitor electronic outpatient referral communication. Recommendations are grounded in a socio-technical model for health information technology [43
]. This model uses 8 interrelated dimensions to identify challenges related to developing, implementing, and using information technology within health care (hardware & software, clinical content, human-computer interface, people, workflow & communication, organizational features, external rules and regulations, and measurement & monitoring). The recommendations are also based on current literature, sound clinical practice, our previous work, and a systems-based approach to understanding and implementing health information technology solutions. We also categorized recommendations according to the dimensions of the socio-technical model with which they are most closely related (Table ). Some recommendations have an established evidence-base and others are based on our experiences or perspectives, but most are not widely adopted by institutions and/or current EHRs. Thus, we believe these recommendations are relevant to all system designers, practicing clinicians, and other stakeholders considering the use of EHRs to support referral communication.
Recommendations Summary and their relation to Socio-Technical dimensions