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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.
A minority of specialists (17%) using service agreements found them very helpful in coordination. We found no association between the use or perceived helpfulness of service agreements and any desirable referral characteristic. These findings are consistent with those of a recent study in which VHA PCPs and specialists reported that existing service agreements were usually ineffective, failing to guide timing of referrals and what information needed to be exchanged.19 However, given the low percentage of “very helpful” ratings, these findings should be considered provisional and the impact of service agreements on referral characteristics should be examined again after that tool has matured in the VHA.

Like templates, service agreements tend to be homegrown, with wide variation in their form and content but similar potential for clinician buy-in. However, their scopes are much broader, use is not embedded in the workflow, and they are not routinely developed in partnership with primary care. These features may explain why, although referrals are a key topic of service agreements, we did not observe an association with referral characteristics. In a study conducted outside the VHA, service agreements were most successful when both parties to the agreement already had stable communication pathways and strong working relationships.23 Research is needed on collaborative efforts between PCPs and specialists to develop service agreements, integrate agreements into the clinical workflow, and test their impact on referral characteristics.

Our findings are broadly relevant because service agreements, referral templates, and e-consults are all tools that are used in non-VHA settings. As healthcare systems move toward interoperable EHRs, there is increased opportunity to build the supports for referrals into the workflow (as they often are in the VHA), such that specialty care coordination is improved. Studies like the current one can inform these efforts.


Our study has limitations. It is cross-sectional and observational; we cannot make causal inferences. We examined 3 tools that vary widely in their form and processes across services and facilities. The overall survey generated a 25% response rate. This response rate is better than that for a recent VHA physician online survey,24 but it is possible that respondents were those who were particularly displeased with the state of coordination with PCPs. Although we sampled widely, not all specialties were equally represented in the sample, introducing the possibility of bias. However, the item response distributions that we observed did not suggest that respondents were predominately negative or positive with respect to their consultation experiences. Future work could focus on or oversample certain specialties to better examine potential differences across them. Our findings may not be generalizable to surgical or other nonmedical specialties or to nonambulatory referral contexts. We examined associations between the helpfulness of tools and referral characteristics only among specialists who reported use of all 3 tools. It may be that perceived helpfulness has different associations with referral characteristics among specialists who use 1 or 2 of the examined tools. Of the sample, 87% reported using e-consults, which may have limited the power of the study to identify differences between that group and the minority of specialist providers who do not use e-consults and who may differ in their referral processes in other ways from the majority of providers who use this referral tool. Finally, our study measured only the specialist perspective. It is likely that the PCPs’ views would differ on the helpfulness of the same tools on the frequency of certain characteristics of the referral process as they experience it (eg, in the consultation note from the specialist). Future work should examine both the specialist and PCP perspectives on coordination of specialty care, because approaches to measuring and improving coordination need to work for both parties (and the patient).


Referral templates were associated with specialists perceiving that referrals were appropriate, clear, and complete. Referral templates may be useful for improving care coordination between primary care and specialty care in the VHA and other practice settings. Existing templates can provide models that could be adapted and broadly applied in collaboration with primary care to improve referrals. The use of e-consults was also associated with perceived referral clarity. Service agreements in their current state do not appear to have an association with desirable referral characteristics. Given that both e-consults and service agreements are intended specifically to improve coordination between primary care and specialty care, efforts are warranted to strengthen their impact. With the number of specialty care visits continuing to increase yearly, further efforts to improve the appropriateness, clarity, and completeness of referrals are needed.

Author Affiliations: Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs (VA) Medical Center (VGV, SQ, AS, JBW, BGF), Bedford, MA; Section of Endocrinology, Diabetes, and Metabolism, Boston University School of Medicine (VGV), Boston, MA; VHA Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID – 10EA), field-based at the Edith Nourse Rogers Memorial VA Medical Center (MM), Bedford, MA; Department of Health Law, Policy, and Management, Boston University School of Public Health (MM, BGF), Boston, MA; Department of Allied Health Sciences, College of Agriculture, Health, and Natural Resources, University of Connecticut (MEW), Storrs, CT; Department of Psychology, University of New Hampshire (JBW), Durham, NH.

Source of Funding: Dr Vimalananda was funded by a VA Health Services Research & Development Career Development Award (CDA 15-070). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the US government.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (VGV, MM, MEW, BGF); acquisition of data (VGV); analysis and interpretation of data (VGV, MM, MEW, SQ, AS, JBW, BGF); drafting of the manuscript (VGV, MM, BGF); critical revision of the manuscript for important intellectual content (VGV, MM, MEW, AS, JBW, BGF); statistical analysis (SQ, JBW); obtaining funding (VGV); and administrative, technical, or logistic support (SQ, AS).

Address Correspondence to: Varsha G. Vimalananda, MD, MPH, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bldg 70 (152), 200 Springs Road, Bedford, MA 01730. Email:

1. Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163-170. doi: 10.1001/archinternmed.2011.722.

2. Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

3. Vimalananda VG, Dvorin K, Fincke BG, Tardiff N, Bokhour BG. Patient, primary care provider, and specialist perspectives on specialty care coordination in an integrated health care system. J Ambul Care Manage. 2018;41(1):15-24. doi: 10.1097/JAC.0000000000000219.

4. Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med. 2005;142(8):700-708. doi: 10.7326/0003-4819-142-8-200504190-00038.

5. Fialová D, Onder G. Medication errors in elderly people: contributing factors and future perspectives. Br J Clin Pharmacol. 2009;67(6):641-645. doi: 10.1111/j.1365-2125.2009.03419.x.

6. Anderson R, Barbara A, Feldman S. What patients want: a content analysis of key qualities that influence patient satisfaction. J Med Pract Manage. 2007;22(5):255-261.

7. Schoen C, Osborn R, How SK, Doty MM, Peugh J. In chronic condition: experiences of patients with complex health care needs, in eight countries, 2008. Health Aff (Millwood). 2009;28(1):w1-w16. doi: 10.1377/hlthaff.28.1.w1.

8. Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89(1):39-68. doi: 10.1111/j.1468-0009.2011.00619.x.

9. Kirsh S, Carey E, Aron DC, et al. Impact of a national specialty e-consultation implementation project on access. Am J Manag Care. 2014;21(12):e648-e654.

10. Greenberg JO, Barnett ML, Spinks MA, Dudley JC, Frolkis JP. The “medical neighborhood”: integrating primary and specialty care for ambulatory patients. JAMA Intern Med. 2014;174(3):454-457. doi: 10.1001/jamainternmed.2013.14093.

11. Kirsh SR, Ho PM, Aron DC. Providing specialty consultant expertise to primary care: an expanding spectrum of modalities. Mayo Clin Proc. 2014;89(10):1416-1426. doi: 10.1016/j.mayocp.2014.04.016.

12. Vimalananda VG, Fincke BG, Qian S, Waring ME, Seibert RG, Meterko M. Development and psychometric assessment of a novel survey to measure care coordination from the specialist’s perspective. Health Serv Res. 2019;54(3):689-699. doi: 10.1111/1475-6773.13148.

13. SurveyMonkey website. Accessed July 1, 2019.

14. Williams TF, White KL, Fleming WL, Greenberg BG. The referral process in medical care and the university clinic’s role. J Med Educ. 1961;36(8):899-907.

15. Kunkle EC. Communication breakdown in referral of the patient. JAMA. 1964;187:663.

16. Zuchowski JL, Rose DE, Hamilton AB, et al. Challenges in referral communication between VHA primary care and specialty care. J Gen Intern Med. 2015;30(3):305-311. doi: 10.1007/s11606-014-3100-x.

17. Stille CJ, Primack WA. Interspecialty communication: old problem, new hope? Arch Intern Med. 2011;171(14):1300. doi: 10.1001/archinternmed.2011.326.

18. Taplin SH, Rodgers AB. Toward improving the quality of cancer care: addressing the interfaces of primary and oncology-related subspecialty care. J Natl Cancer Inst Monogr. 2010;2010(40):3-10. doi: 10.1093/jncimonographs/lgq006.

19. Kim B, Lucatorto MA, Hawthorne K, et al. Care coordination between specialty care and primary care: a focus group study of provider perspectives on strong practices and improvement opportunities. J Multidiscip Healthc. 2015;8:47-58. doi: 10.2147/JMDH.S73469.

20. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15(9):626-631. doi: 10.1046/j.1525-1497.2000.91119.x.

21. Forrest CB, Glade GB, Baker AE, Bocian A, von Schrader S, Starfield B. Coordination of specialty referrals and physician satisfaction with referral care. Arch Pediatr Adolesc Med. 2000;154(5):499-506. doi: 10.1001/archpedi.154.5.499.

22. Gupte G, Vimalananda V, Simon SR, DeVito K, Clark J, Orlander JD. Disruptive innovation: implementation of electronic consultations in a Veterans Affairs health care system. JMIR Med Inform. 2016;4(1):e6. doi: 10.2196/medinform.4801.

23. Carrier E, Dowling MK, Pham HH. Care coordination agreements: barriers, facilitators, and lessons learned. Am J Manag Care. 2012;18(11):e398-e404.

24. Linsky A, Simon SR, Stolzmann K, Bokhour BG, Meterko M. Prescribers’ perceptions of medication discontinuation: survey instrument development and validation. Am J Manag Care. 2016;22(11):747-754.
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