Retooling Referrals

Problems with referrals, says Marge Crossley, an administrator at a three-physician pediatric nephrologist practice in Philadelphia, begin when she tries to schedule an appointment. "Parents call and don't know what's going on," she says. "[Primary-care] physicians don't even tell the parents how quickly the child needs to be seen."

And once the appointment has been made, Crossley adds, "we have to fax and call right up to the day the patient comes in" for information like test results and blood work that are pertinent to treatment. "Ninety-five percent of the time, the referring physician's office doesn't send anything in," she says.

"I've had to drive across town to get X-rays, or run downstairs to get some information" when the patient arrives and the chart is incomplete, says Barbara Hale, a practice manager at a North Carolina neurosurgery practice. "If the patient shows up and the information still isn't there, we have to get on the phone again."

Patients themselves get on the line if they show up without a referral form at Greater Chesapeake Hand Specialists in Lutherville, Md. "We don't let the patient see the doctor without the referral," says administrator Patti Levin. "We usually call the patient ahead of time if we don't see [a form] in the chart, but if they show up without one, we invite them to call the primary-care physician to have it faxed over."

Does your practice experience these kinds of disconnects and delays related to referrals? You're not alone. According to a study published in May 2000 in the Archives of Pediatric and Adolescent Medicine, improvements in the referral process can be achieved through better communication between primary-care physicians and specialists.

Researchers examined 963 referrals made from the offices of 122 pediatricians in a national practice-based research network. They found that only half of the primary-care physicians sent pertinent patient information to a specialist when making a referral, and just 39 percent of the pediatricians scheduled appointments for patients they were referring to other physicians. Researchers found that specialists were three times more likely to send results and recommendations when primary-care physicians personally scheduled patient appointments and sent relevant information. The lesson? Physician communication helps to smooth the bumps in the referral process.

Getting it right

Clearly, making a simple phone call to a specialist about the referral could save your patient an unnecessary trip. "Thirty-five percent of our patients can be better managed by a primary-care physician or a neurologist," says one neurosurgeon who works with Hale. "I would rather talk to [primary-care physicians] on the phone for three minutes before they send the patients over here. Sometimes, I have to send them back."

Hale says that after the referring physician's office calls to make an appointment, a clinician reviews the referral form to determine if neurosurgery is the best course of care, and if the patient's needs are urgent. "We always ask if patients need to be seen as soon as possible, or if they can wait for the first available appointment," she explains. "After the physician has seen the case, we sometimes have to go back and explain that the patient's needs are not urgent, or that it is an inappropriate referral."

To solve this problem, the practice began sending quarterly newsletters to 300 or so of the community's referring physicians. "In the newsletters, we publish different advances and techniques in neurosurgery, and when it's appropriate to send a patient to a neurosurgeon," says Hale.

The neurosurgeon in Hale's practice reports that the amount of inappropriate referrals has decreased as a result of their efforts. "I'm finding a lot more primary-care physicians are conducting magnetic resonance imaging tests (MRI) in conjunction with anti-inflammatory medications," he says. "They didn't do that before -- they just took the MRI and sent the patient to us." The surgeons are now receiving more physician-to-physician calls, which are helping to cut down on inappropriate referrals.

Connectivity solutions

Some physicians are electronically "plugged in" to their patients' care. Saint Joseph's Hospital in Marshfield, Wis., in partnership with IDX Corp., has been developing Web-based software that allows referring physicians to access patients' records on a secure Web site. It's a smart solution for Saint Joseph's because the majority of referring physicians live more than 30 miles away from the hospital.

"We send admission notification [to the referring physicians], so they know their patient has been admitted to the hospital," says Lori Brenner, marketing manager for Saint Joseph's. "Physicians can log on from any computer that has Internet access. They can then see lab results, medications administered, operative notes, orders, radiology interpretations, and discharge summaries." Various security measures assure that physicians view only their own patients' records.

"We expect that all physicians send discharge summaries to referring physicians, but that doesn't always happen, so this allows the referring physician to have a little more control over the information," Brenner continues, emphasizing that the software is not meant to replace communication between physicians, but provide them with information when they want it.

"What's most important is that I will be able to get access to the patient's medical record before I get a letter from the attending or a discharge summary," says Pete Sanderson, a primary-care physician practicing in Stevens Point, Wis. He uses the program when he sends a patient with an acute problem, like a heart attack, to Saint Joseph's Hospital.

"They'll be discharged from Marshfield and I'll see them in my office prior to the time that the catheterization report will be back," he says. "It saves me the time I'd otherwise take to call the hospital, and [hospital] staff doesn't have to look up the report."

Brenner says that training time for the program is minimal. "I pay a visit to a physician organization, do a demonstration, and give them access [to the system]. Once we have their names, it takes about five minutes to set them up," she explains. Nearly 100 physicians affiliated with the hospital have access to the system, which Brenner hopes other local physicians will consider using.

Referrals can still be managed in an efficient manner without a software program -- by just using a telephone. "If you're going to refer someone, send us information and call, doctor-to-doctor," says Crossley.

Andrea King can be reached at editor@physicianspractice.com.

This article originally appeared in the Spring 2002 issue of Physicians Practice.