Physicians and patients do not like the current referral process. It is labor intensive, full of gaps and frustrating for everyone involved. There is a golden opportunity right now to improve referrals and help rebuild trust in healthcare as well as become more patient centric.
Broken or As Designed?
Ideally here is how a referral should work:
- Patient goes to their Family Doc with an issue
- After speaking with and examining the patient, the Family Doc is not 100% sure what is causing the issue, so they refer the patient to a local Specialist
- The patient’s medical information is transferred seamlessly from the Family Doc to the Specialist
- After reviewing the information, the Specialist sets up an appointment with the patient who is notified via phone/text/email. The Family Doc is also notified of the appointment
- After visiting the Specialist, the patient is prescribed mediation + treatment that will address the issue
- The diagnosis, notes and treatment plan are sent from the Specialist to the Family Doc
Unfortunately, this is often far from reality.
For one, the seamless transfer of medial records is not something we have achieved. In addition, the originating physician often has to call the Specialist to (a) ensure their patient is seen and (b) to find out what the outcome of the visit is. Finally, the patient often is the one who has to call to make Specialist appointments and shuttle results back to their Family Doc.
“From the perspective of the Family Doc, the process is a black-box,” said John Ellis, Director of Growth at ReferralMD, makers of a referral management platform. “They don’t know what happens, but they want to. So they have to spend time, effort and money on staff to call patients and Specialists to find out what happened.”
Ellis (an optimist), believes that the referral process is not broken, but is functioning “as designed”. In the past, there was no incentive for either the originating physician or the physician receiving the referral to ensure the process was smooth. The party with the most incentive was the patient, who lacked any power to affect or fix the process.
As a result, we ended up with a process that is a series of hand-offs without a closed loop. “It’s like the sketch ‘Who’s on First?’,” commented Ellis.
Multiple Challenges
There are multiple challenges faced by all three parties involved in the referral process.
From the patient’s perspective, it is unclear:
- Who will be making the appointment with the Specialist
- If the originating physician checked to ensure that the Specialist accepts the patient’s insurance or what the out-of-pocket costs may be
- What they should do after seeing the Specialist
From the originating physician’s perspective, they are faced with:
- Fielding calls from their patients who are confused about the referral process
- Having to call Specialists to find out how to best send over patient medical records, confirm appointments and find out results
- Unhappy patients who had to go to the ER after being unable to get an appointment with the Specialist or not seeing them in time to address their issue
The receiving physician (Specialist) has the following challenges:
- Lots of referrals from different systems – some electronic, some via fax
- Different levels of detail in the received medical charts – too much, too little, very few are just right
- Different follow-up expectations from different referring physicians – some want to be kept up to date on every detail, others just want a summary at the end
It is easy to see how each party views the others as part of the problem and for years these frustrations remained as none of the parties had an incentive to fix the process. Thankfully that is no longer the case.
Incentive to Fix Referrals
“Healthcare has not traditionally been consumer-friendly,” stated Ellis. “But that is slowly starting to change now that patients have more healthcare options available to them, are more educated on their healthcare choices and have higher consumer expectations.”
In many urban markets, patients now have many options on who they see for their care. They no longer have to put up with an inferior experience. Smart practices have sensed this shift and are changing their operations and adopting technologies to be more patient-centric. This includes being more hands-on when it comes to referrals.
According to Ellis, there is also newfound incentive for physicians receiving referrals (Specialists) to fix the process: “If Specialists do not reduce their barriers and make referring patients easy, Family Docs will simply send their patients elsewhere. Like patients, physicians also have more care choices.”
Simple First Steps
What can be done to fix referrals? Ellis has two simple words for physicians: “Be Proactive”
For physicians receiving referrals, this means proactively updating the originating physician on the status of their patient and not waiting for them the call for an update. For now, Ellis recommended not worrying about the modality of that update: “If it has to be fax, then use fax. If there is a different electronic mechanism that can be used, then use it. But don’t let the technology be the excuse for not being proactive. Use a carrier pigeon if you have to.”
Proactively updating the originating physician eliminates one of the biggest frustrations from the current process and any physician that does this will stand out from their peers thus earning more referrals.
For physician making referrals, being proactive means reaching out to Specialists that you have relationships with to find out how they would prefer to receive the referral. This includes how patient information should be transferred, how they would prefer the appointment to be made, and how the update will be sent.
By doing this, physicians will gain the trust of the Specialists who will be more welcoming of their patients.
“Think of referral networks like a spousal relationship,” recommended Ellis. “Don’t wait to be asked to do the dishes, just do the dishes and everyone is happy.”
Recognizing Healthcare is Not Standardized
To fix referrals fully, Ellis stresses that we must accept a key reality of healthcare – that it is not standardized. “As much as we wish that everyone was on the same system or using the same data standard, that simply isn’t the case,” said Ellis. “Healthcare is heterogenous and for the foreseeable future there will be multiple systems that we need to work with.”
For Ellis, this means that we need to stop the “app-approach” to fixing referrals and he used the example of Apple’s iMessage to illustrate the point.
“When everyone in a group is using iMessage to talk and text, it works great,” explained Ellis. “The second an Android user tries to join the conversation nothing works for anyone. We need to stop designing healthcare solutions like this. We need solutions that recognize that healthcare is fragmented and that everyone involved in referrals is potentially using a different system, protocol or standard.”
Closing Thoughts
I agree with Ellis’s statements. I think there are some very simple ways the referral process can be improved – not just for the benefit of patients, but for all parties involved. I especially liked his comments about needing solutions that recognize healthcare is a jumble of systems and standards. Just because one physician wants to receive referrals via fax shouldn’t prevent them from being part of the network. That same physician may be the most patient-centric specialist who proactively keeps referring physicians in the loop.
In our interview, Ellis purposely avoided promoting ReferralMD’s platform as a solution and I applaud him for doing so. On his behalf, I will say that technology can definitely play a role in improving referrals, especially at scale when manual processes break down. A busy group practice, for example, cannot possibly keep up with all the inbound/outbound referrals and all the different protocols. You need technology to help you manage it. Thankfully solutions like ReferralMD’s exist to fill this need.
Watch the full interview to learn more about:
- How the disjointed referral process poses potential threats to patient safety
- The role consumerism plays in the evolution of referral management
- Why it’s all about relationships when it comes to referrals
- When you should consider digitizing your referral process (the ROI tipping point)
Learn more about ReferralMD: https://getreferralmd.com/
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hello there,
I found your post really interesting because I am currently seeing 5 different specialists. It is hard for me to keep up with all the paperwork I have to fill out every time I go or I get referred somewhere else. I also find it really frustrating to repeat all my sad story to start from zero instead of the ideal you described where my specialists and PCP would seamlessly communicate with each other. This would actually build upon the care I am already receiving instead of creating a redundant, time consuming, costly, and painstaking process. to be honest this is the cause I often fall behind my compliance with treatment, I get discouraged. I am glad there are advances in technology being applied to close that gap in communication and making this whole process more effective for everybody involved.
What you think is the biggest barrier to overcome in the process of implementing this technology?
Hello
This article was really on point. I currently work with a system that uses technology to send referrals to specialists who are in-network to see a patient we are referring. Ninety percent of the referrals are processed electronically, however, there are those that we may think are in-network that are no longer in-network, or that particular specialist is not seeing patients for that specific issue. When that happens we have to cancel that referral and start the process all over again. Fortunately, this can all be done electronically. Unfortunately, who is the person that updates the system when the specialist is no longer in-network?
Thank you for sharing your story Myrna. There are many barriers – perceived and real to solving this problem. One is the lack of interoperability – making it difficult for physicians so share files with one another. There is also the CYA factor. Some physicians prefer to have you repeat your patient story because then they can hear it all themselves vs rely on someone else’s interpretation. Cost, however, remains the biggest barrier. Until recently there wasn’t a clear ROI for practices to fix the problem of referrals. Now with value-based-care and other initiatives, there is more incentive. It’s still slow progress and unfortunately stories like your own will continue to happen. The most important thing is continue to tell these stories. You are not alone and the more they are told, the harder they are to ignore.
Nichole, you are highlighting one of the limitations of electronic systems. They are only as good as the data they are built on. If the system that tracks who is in- vs out-of-network isn’t connected to the electronic referral system, then you will get out of sync as you illustrate with your example. Still at least your organization has made the investment so that the the majority of referrals are smooth. Dealing with these edge cases is still much better than having to manually followup with referrals. THAT is a complete waste of resources.
Thanks for sharing, Myrna. It is sadly a story I hear all the time when connecting with practices. A big barrier to implementing solutions like this can be the current ‘Technical Debt.’ Many practices have been forced to add different tools that don’t ‘connect’ to the point that they begin to look like a Rube Goldberg Machine, so unwinding all of those pieces can seem daunting. I can tell you that over the past 5 years, it seems like we’re making progress, so I’m hopeful we can continue this path to make sure there are no more stories like yours.
Hi Nichole. We have seen this many times, where a large health system has a solution. However, it only applies to their employed physician groups and begins to break down at the affiliated level. Having a solution that can connect the entire network while sending referrals to affiliated and non-affiliated providers using the same solution is very helpful.