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The American Journal of Managed Care August 2019
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Tools to Improve Referrals From Primary Care to Specialty Care
Varsha G. Vimalananda, MD, MPH; Mark Meterko, PhD; Molly E. Waring, PhD; Shirley Qian, MS; Amanda Solch, MSW; Jolie B. Wormwood, PhD; and B. Graeme Fincke, MD
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Tools to Improve Referrals From Primary Care to Specialty Care

Varsha G. Vimalananda, MD, MPH; Mark Meterko, PhD; Molly E. Waring, PhD; Shirley Qian, MS; Amanda Solch, MSW; Jolie B. Wormwood, PhD; and B. Graeme Fincke, MD
Data from a national survey of Veterans Health Administration specialists indicate that referral templates may improve the appropriateness, clarity, and completeness of primary care–specialty care referrals.
DISCUSSION

Referrals from primary care to specialty care can be difficult to coordinate, and shortcomings are longstanding.14,15 The referral request from primary care to specialty care is a critical first step in coordination as it focuses and informs the specialist’s consultation. Appropriate, clear, and complete referrals increase the likelihood that the specialist can provide timely, thorough, and efficient care. Our findings about shortcomings in the referral process are consistent with those in the literature.3,8,16-21 Our study extends this knowledge base by examining how commonly used mechanisms to coordinate care affect important referral characteristics.

We found that VHA specialists who use referral templates were more likely to report that referrals were appropriate, clear, and complete more than half the time, and specialists who used e-consults were more likely to report that referrals were clear. Use of service agreements was not associated with any referral characteristic. Among specialists who used all 3 tools together, those who reported referral templates to be very helpful were also more likely to report that referrals were clear and complete more than half of the time.

Only about half of respondents indicated that referrals were appropriate more than half the time. Reducing inappropriate referrals is critical to ensuring timely access to care. However, there are often differences in what specialists and PCPs consider appropriate for referral; there may also be differences in what is considered appropriate for a given modality when other modalities are available (eg, face-to-face vs e-consult). Just 67% of specialists in our study reported that referrals were clear more than half the time. If referrals are not clear, specialists may address the wrong issue, or they may address the right issue but too narrowly or too broadly for the PCP’s and the patient’s purposes.

An even lower percentage of respondents—just 25%—reported that referrals were complete more than half the time. These results show that although data are technically available to all providers through the shared EHR, specialists still look for relevant information to be selected and included alongside the referral question. This can be helpful because specialist errors in identification of relevant data can lead to their repeating work, duplicating tests, or suggesting treatments that have already been found ineffective or harmful. Also, PCPs are likely to have a high-level understanding of the relevant data such that they can provide meaning within the referral over and above that gleaned by specialists from review of the day-by-day record. PCPs are thus in a strong position to translate a list of data into useable and meaningful information. On the other hand, PCPs may not know exactly what information would be useful for the specialist’s evaluation. Including many details just because they might be important is a waste of their effort and limited time.

Referral templates may be useful for improving the appropriateness, clarity, and completeness of referrals. Templates can include a field that specifies the need for a clear question and can be tailored so that they guide the PCP as to what data should be included and whether referral is indicated for a specific given condition. Templates in the VHA are embedded in the EHR as the tool by which to request a referral. They are simple to create and require a minimum of effort to incorporate into the workflow.

Referral templates are usually “homegrown” and vary widely in their content and specificity of instructions they provide. Our data suggest that templates must be carefully crafted and implemented in order to improve referrals. Only 26% of specialists who used all 3 tools reported that templates were very helpful, but those specialists were more than 3 times as likely to report that referrals were clear and complete more than half the time.

It is important to note that in other studies, PCPs have reported that templates can be poorly laid out, be overly rigid in their structure, require irrelevant details, or require that labs and tests be ordered for which interpretation is within the specialist’s scope, but for which responsibility for follow-up lies with the PCP.3,16 Future work should examine specialty- and condition-specific templates already in use and identify which are perceived as most helpful by specialists and PCPs alike. Standardized templates modeled on those rated as very helpful by both parties could improve referrals at low cost and improve the efficiency and quality of specialty care more widely.

We observed an association between e-consult use and referral question clarity. It is possible that PCPs with the option to decide between face-to-face patient consultation and e-consult are prompted to articulate the purpose of the referral more clearly; this is an area for future study. It is notable that use of e-consults was not associated with referral appropriateness given that e-consults are intended as a tool to promote the more clinically appropriate routing of referrals. E-consult use is robust in the VHA, but that usage includes “curbside” questions that might otherwise not be formally asked (and so would not have led to an inappropriate referral).22 Therefore, the impact of e-consults on reducing inappropriate referrals may not be great. Combining coordination tools, for example, by applying referral templates to e-consult requests, may result in a stronger association between e-consult use and referral clarity and completeness.


 
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