Follow-up Actions on Electronic Referral Communication in a Multispecialty Outpatient Setting

Abstract

OBJECTIVES: Electronic health records (EHR) enable transmission and tracking of referrals between primarycare practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronic referral communication in a large multispecialty VA facility. METHODS: We retrieved outpatient referrals to five subspecialties between October 2006 and December 2007, and queried the EHR to determine their status: completed, discontinued (returned to PCP), or unresolved (no action taken by subspecialist). All unresolved referrals, and random samples of discontinued and completed referrals were reviewed to determine whether subspecialists took follow-up actions (i.e., schedule appointments anytime in the future) within 30 days of referral-receipt. For referrals without timely follow-up, we determined whether inaction was supported by any predetermined justifiable reasons or associated with certain referral characteristics. We also reviewed if PCPs took the required action on returned information. RESULTS: Of 61,931 referrals, 22,535 were discontinued (36.4%), and 474 were unresolved (0.8%). We selected 412 discontinued referrals randomly for review. Of these, 52% lacked follow-up actions within 30 days. Appropriate justifications for inaction were documented in 69.8% (150/215) of those without action and included lack of prerequisite testing by the PCP and subspecialist opinion that no intervention was required despite referral. We estimated that at 30 days, 6.3% of all referrals were associated with an unexplained lack of follow-up actions by subspecialists. Conversely, 7.4% of discontinued referrals returned to PCPs were associated with an unexplained lack of follow-up. CONCLUSIONS: Although the EHR facilitates transmission of valuable information at the PCP-subspecialist interface, unexplained communication breakdowns in the referral process persist in a subset of cases.

Challenges in Referral Communication Between VHA Primary Care and Specialty Care

“…8,15,[17][18][19][20] EMRs can also be applied specifically to facilitate the referral process, one of the most common and important types of primary-specialty care communication. 21,22 The Veterans Health Administration (VHA) is a fully integrated healthcare system with a well-developed, comprehensive EMR system. The VHA's EMR is the dominant method of connecting primary and specialty care at the VHA, serving as the vehicle for conveying requests from primary care for specialty consults as well as specialist recommendations back to primary care.…”

“…One study conducted within the VHA, however, identified a subset of cases evidencing unexplained breakdowns in primary-specialty referral communication. 21 The EMR alone, therefore, may not be "enough" to solve the problems in primary-specialty communication. 4,9,13,23 Little is known about referral communication between primary and specialty care in the VHA and similar healthcare systems that already benefit from an integrated delivery system and shared EMRs.…”

Implementation Science Workshop: Implementation of an Electronic Referral System in a Large Academic Medical Center

“…However, even when supported by technology, referral communication between PCPs and specialists can be less than satisfactory 24 and in the past has led to new communication challenges and unintended consequences, often related to non-technical factors. 11,25 Thus, methodological approaches for implementing and evaluating outcomes of health IT-related communication interventions need to address both technological (software/ hardware) and non-technological Bsocial^(e.g., organizational components, people and workflow) 26 contextual factors. These approaches, for instance, must be grounded in an understanding of how referral processes fit within the complex Bsociotechnical^context of health IT-enabled care.…”

“…These approaches, for instance, must be grounded in an understanding of how referral processes fit within the complex Bsociotechnical^context of health IT-enabled care. 25,27 Most existing implementation frameworks are not sufficient to specifically evaluate health IT-based quality improvement or patient safety-related interventions. To effectively assess health IT-based interventions, frameworks or approaches must consider technology within the larger sociotechnical system in which it is implemented.…”

“…In a previous work, we found that at 30 days post an electronic referral, 6.3 % of referrals had an unexplained lack of followup action by subspecialists, and 7.4 % of discontinued referrals returned to PCPs were associated with an unexplained absence of follow-up. 25 Some issues must be proactively thought through prior to implementation. For example, with a few easy clicks, specialists could receive so many referrals for trivial problems that they wouldn't have time for the important ones, and this could create a huge backlog.…”