Referral silence irks specialists, primary care doctors alike

Sometimes, referring patients can feel like sending them into the abyss.

Primary care physicians may wait and wait for word about how the referral went, but no information comes their way. Likewise, specialists may greet a new patient in the exam room with no patient history or reason for the visit provided by the referring doctor.

Poor communication between primary care physicians and specialists on referrals and consultations is an all-too-common problem that has real repercussions on patient care, experts say. It can lead to duplicate lab tests, repeat procedures, wasted time and resources, conflicting prescriptions, and potential harm to patients.

"This is a big problem," said internist Redonda Miller, MD, associate professor of medicine and vice president for medical affairs at Johns Hopkins Hospital in Baltimore. "If you ask physicians at Johns Hopkins who refer patients ... their No. 1 concern is they won't hear anything back."

The same is true of physicians nationwide, according to a study in the Jan. 10 Archives of Internal Medicine. Researchers surveyed 4,720 doctors and found a wide chasm between primary care physicians' and specialists' perceptions of how frequently they send and receive information on patients for referrals and consultations.

Though 69.3% of primary care physicians said they send specialists notification of a patient's history and the reason for the consultation all or most of the time, just 34.8% of specialists said they routinely receive such information, according to the study.

Meanwhile, 80.6% of specialists say they send consultation results to the referring physician all or most of the time, but only 62.2% of primary care physicians say they ever get that information.

"Communication goes both ways," Dr. Miller said.

Previous research yielded similar results. An October 2006 Pediatrics study, for example, found that specialists reported receiving communication from referring primary care physicians in 50% of cases. Primary care doctors said they had communication with specialists after 84% of initial consultations.

Such studies help to quantify the extent of an issue most physicians have experienced firsthand, said Glen R. Stream, MD, president-elect of the American Academy of Family Physicians.

A lack of time

The problem of poor communication among physicians centers around time, which physicians never seem to have enough of. The fee-for-service system pays based on the number of patients treated and doesn't allow much flexibility, said Ann S. O'Malley, MD, MPH, co-author of the Archives study and senior researcher at the Center for Studying Health System Change in Washington, D.C.

Primary care physicians spend an average of 10.7 to 18.7 minutes face-to-face with each patient, according to the study. "You don't get paid to take time out of your day to pick up the phone and call the specialty doctor," she said.

Those time pressures are getting worse as administrative burdens increase, said Marc Gillinov, MD, a thoracic and cardiovascular surgeon with the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic.

"We spend increasingly more time in administrative tasks that are only peripherally related to patient care," he said. "It's only going to get worse, and it's getting worse at an increasingly rapid rate."

As an internist, Dr. Miller routinely juggles filling out medical records and administrative forms required for each patient during visits that are already too short. Another problem is that as practices transition to electronic medical records, many networks can't communicate with one another, said Dr. Stream, a family physician in Spokane, Wash. That makes it difficult for physicians to share data and records.

"In many areas we have gone from having paper silos to ... electronic silos," he said.

Physicians with higher proportions of patients with chronic conditions were more likely to report sending patient information to other doctors, the Archives study said. But they also were more likely to say they experienced problems receiving information from colleagues in a timely manner.

Significantly fewer specialists received quality reports on patients with chronic conditions compared with primary care physicians, one of the more surprising findings of the study, Dr. O'Malley said. "So many of the quality improvement efforts seem to target primary care right now," she said.

Experience and the type of community in which a physician practices were major factors in how well doctors communicated. Physicians with 20 or more years of experience were more likely to report routinely sending and receiving information, as were physicians who worked in smaller, more rural communities, the study said.

In both instances, relationships mattered, Dr. Stream said. More experienced doctors get to know referring physicians over time and learn the importance of good communication. And physicians in smaller communities have a smaller referral network.

"It has to do with the sense of medical community," he said. "If you're in a smaller medical community, you tend to know those people better and have better relationships."

Moving toward solutions

The study points to possible solutions in advances in health information technology, systems that allow physicians to spend more time with patients and coordinated care that uses staff support to aid in transferring information.

For example, physicians who are a part of a health maintenance organization, community health center, hospital or medical school practice with built-in staff support send their information to specialists at higher rates than those in group practices.

Johns Hopkins and the Cleveland Clinic have automatic fax systems to facilitate better physician-to-physician communication. When patients arrive at the hospitals, they are asked which outside doctors should receive information about their visits. That information is then faxed directly to referring physicians when patients are discharged.

The Cleveland Clinic has a website called DrConnect, which allows referring physicians to access a patient's full medical records.

A Johns Hopkins initiative identifies an individual responsible for coordinating handovers of care when a patient leaves the hospital to ensure that the physician who treats him or her as an outpatient has essential information, Dr. Miller said.

Key to improving communication is taking more time, making information accessible across different systems and encouraging physicians to work as a team, said Christopher Stille, MD, MPH. He is professor of pediatrics and section head of general academic pediatrics at the University of Colorado and The Children's Hospital at Denver. Dr. Stille also was a co-author of the 2006 Pediatrics study.

"A lot of it goes back to a million years ago when we were all trained," he said. "Physicians were trained to be the all-knowledgeable individual. It is not always easy to play in the sandbox."

Though some changes in medical education encourage teamwork, Dr. Stille said medical schools should have more interdisciplinary programs to give physicians more teamwork training with other health professionals, including nurses and physician assistants.

New models of care such as the medical home and accountable care organizations would help by facilitating coordination, providing financial incentives for better communication, encouraging the use of support staff and requiring physicians to take responsibility for coordinating a patient's care, the study said.

"We're headed in the right direction," Dr. Stille said. "I'm worried that we might not follow through with a lot of the health care reforms and if we don't follow through with that, we're going to have more problems."