Closing the referral loop: Perspectives and experiences of primary care and specialist physicians

Every year, millions of referrals are made by primary care physicians in the U.S. for patients needing consultations with specialists. The intention is for patients to be seen by specialists and then to return to their primary care providers, completing a process known as a referral loop. However, between a third and half of referral loops are not closed, potentially resulting in patients not getting the care they need, which can compromise safety and health outcomes.

Little research has been published on closing external referral loops. A study led by Regenstrief Institute Research Scientist April Savoy, Ph.D., explores primary care physicians' and specialists' perceptions of the causes and experiences with referral loop breakdowns. Both primary care and specialist physicians reported technological and organizational barriers to the successful completion of the referral loop.

Among the most significant barriers to closing referral loops, physicians noted the inability of electronic health record (EHR) systems to communicate or share information across health care systems and clinicians' continued reliance on fax machines or patient conveyance of paperwork.

Physicians interviewed by the study team reported feeling helpless. They perceived competing demands among institutional policies and additional efforts needed to devote to patients and caregivers.

Breakdowns in closing the referral loop can occur at any point, including when a consultation is completed but the referring clinician is not informed of the results. This communication failure may result in failure to treat or inappropriate treatment.

"If there's a breakdown, whether due to communication, inaccessible information, payment, or other factors, patient care may be compromised. When referral loops aren't closed, there can be an increase in patient safety risk, malpractice lawsuits, clinician burden, and other adverse events," said Dr. Savoy, a human factors engineer and health services researcher.

"In addition to technological barriers, we learned more in this study about organizational barriers for referral loops involving inconsistent information-sharing policies across health care systems."

"Patients referred to specialists are not feeling well and are often stressed. They're trying to find solutions and be treated. To add to their burden and make them responsible for facilitating communication between physicians, conveying messages, often including medical jargon, or transferring information is not an ideal situation," said Dr. Savoy.

Looking to the future and applying this line of research to clinics, she plans to develop and refine lists of requirements for technologies, organizational policies, and workflows to address better the barriers—perceived or experienced by referrers and those with whom they consult—to complete external referral loops.

"We hope, with the information we have captured in this study on the commonalities and differences across health care systems and even within specialties and clinics, we can apply human factors engineering concepts to guide future design and implementation of processes to help ensure that all patients and their caregivers and clinicians have more efficient experiences with referrals, contributing to better quality of care," said Dr. Savoy.

"Consultants' and referrers' perceived barriers to closing the cross-institutional referral loop, and perceived impact on clinical care" is published in the International Journal of Medical Informatics.