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A modest proposal: making referrals patient-friendly.

Specialization among physicians has grown to more than 40 specialties and resulted in continuity of care being a serious problem for patients, particularly those 65 and older.



As persons age, they encounter both chronic and acute medical problems that overlap and require care from a variety of specialists. Delays of days or weeks are common when physician visits are scheduled, resulting in a loss in continuity of care. This problem will only grow in the years ahead as the older age group increases from its current 13.2 percent of the U.S. population to nearly 20 percent by 2050.

By 2050, because they use an average of five times as many health care services as people under 65 years of age, this group will be using more than 50 percent of total U.S. health care resources.

A typical scenario occurs when a physician determines that a referral is in order. At that point, the patient usually asks the physician who should be contacted and is informed that Doctor X is knowledgeable in that specialty. The name of Doctor X is noted on a prescription pad and the patient is told to call for an appointment.

This referral system has been in place for decades and reflects a pattern of practice that was traditionally associated with family physicians prior to the development of widespread specialization. In bygone times, patient referrals were a rarity and occurred when the family practitioners decided the patient should see a surgeon.

As a result of the widespread development of specialization, it is now common for a patient to be referred to two, three, or more specialists. The traditional referral system remains the same.

It is up to the patient to schedule an appointment in keeping with the availability of time on the referred physician's schedule. This system ignores patient convenience and responds solely to physician convenience.

Scheduling problems

From the viewpoint of a practicing physician, the scheduling of patient visits is not a problem. The physician informs his or her personnel of the hours in the day and the days of the week that time is available for scheduling patient visits.

The office staff books appointments from patients. If the schedule changes, the office staff telephones those patients who have been scheduled and shifts appointments times and dates to open slots in the schedule.

From the perspective of the patient, this traditional referral system often leads to delays of days or weeks if more than one specialty is needed. An exception occurs if the physician determines there is an emergency situation. In that case, the physician will likely phone the referred physician to communicate the seriousness of the problem and request an early appointment for the patient.

The difficulty with the existing method of making referrals is that it only serves physicians. It is a system that has remained unchanged for decades. In the past when medicine was dominated by general practitioners, the organizational model was individual ownership, or a partnership if two or more physicians shared the practice.

Even though there are now more than 40 fields of specialization, the organizational characteristics of medical practice remain the same, even though the solo practitioner is a rarity. The solo practitioner has largely been replaced by partnerships and confederations of single-specialty and multispecialty groups that vary in size from very small to very large groups that number in the hundreds.

Yet these new organizations still retain the traditional system that requires the patient to take the initiative in scheduling a visit to the referred physician. This seems reasonable given that medical care is a personal service that can take place only when the physician and the patient meet in a face-to-face relationship.

However, delays of days and even weeks occur because the referred physician has his or her own schedule for seeing patients. With the growth in specialization, the result is a loss in continuity of care. As long as the responsibility for making a referral appointment is the patient's, there will continue to be delays. This lack of coordination may not be a problem for physicians, but it becomes a problem for patients.

Even in large multispecialty groups, there are often significant delays because the referring physician is usually unaware of the appointment openings in the schedule of the physician to whom he or she makes the referral, even though both physicians are members of the same practice group. There will still be delays, but patients staying in the group will usually experience fewer of them.


Go electronic

Given the advancements in the use of electronic systems in medical practice, it may seem odd that patient referrals have not been addressed. To date, the emphasis of the electronic systems has been focused on avoiding clinical errors and on enhancing the quality of medical care.

Given the patterns that now are the dominant form of organization for medical practices, there is no practical way to reduce the loss of continuity of care, even with the use of electronic systems.

A medical practice can use electronic medical records, computerized physician order entry (CPOE), pharmaceutical bar coding, electronic prescriptions, and electronic business systems. While these tools are helpful in avoiding errors and enhancing the quality of medical care, they have little or no impact on the continuity of care.

The partnership method of organizing medical practices is a detriment to adapting to changes that will be needed as technological advances become widely acceptable to the public. As a result of these advances, public expectations about medical care will also be affected.

Just as it reacted to the replacement of mom and pop grocery stores by supermarkets offering customer convenience and a wider variety of choices, the public has come to expect the same kind of responsiveness from the medical profession.

Physicians who cling to organizational patterns that are outdated and unresponsive to the public interest will face increasing discontent from patients who have come to appreciate that the electronic age offers greater convenience and less waiting time.

In today's world, the public will likely be less tolerant of delays in coordinating scheduling of visits to referral physicians' offices. In addition, patients have come to believe that the use of electronic systems makes the transfer of clinical information between physician offices a simple procedure that is accurate and complete so that the information is readily available at the time of the referral visit.

Improving the coordination of referrals requires a different and more comprehensive organizational form of practice. Instead of small economic units organized as partnerships, the method of organization needed is a corporate model, either for-profit or not-for-profit.

The major impediment to improvements that are available from the application of electronics is rooted in the organizational structure of medical practices. The growth in specialization has led to an increasing number of small, separate economic units that have no organizational relationships to one another.

Physicians in the same group practice may appreciate the use of electronic systems in improving quality and accountability within the confines of the practice, but they remain unconcerned about applications that would be helpful in arranging for patient referrals to specialists who are not part of the group.

This will continue to be the case as long as electronic systems as focused only on the needs of physicians in the same group practices. What is needed is an electronic system that provides links between various groups in the same community in order to accommodate patients as well as physicians.


It is tempting to suggest that the Mayo Foundation is a model that should be adopted, because it integrates all of the patient services in a way that minimizes the responsibilities of patients for looking after coordination of services that are a necessity in non-Mayo situations.

To make this occur would require most of the physicians in a community to give up their ownership of practices and join in a large group practice with a significant number of administrative employees to make the system work to the advantage of patients.

In a real sense, this will not happen. People attracted to medical careers, particularly those who opt for private practice, typically have a strong desire to be responsible for their own decisions and livelihood. By and large, they appreciate independence and being accountable for all their professional activities.

However, the same results can be accomplished without requiring physicians to give up ownership of their practices by establishing an electronic medical practice system (EMPS). Because of privacy requirements, the EMPS would need to be available only to practicing physicians who would be approved for membership and would pay a monthly subscriber fee to participate.

Such a system could be operated by a hospital or by a county or state medical society to ensure the proper controls. The EMPS would be used for transmitting patient data from one physician's office to a referral and for securing appointment times for referred patients by examining the open slots in the referred physician's schedule.

The EMPS could also print out directions to the referred physician's office, as well as any instructions to the patient in preparing for the referral visit.

Although community health information networks (CHINs) were intended to provide a mechanism for health care providers to share information, they were not intended for use in scheduling patient visits from one physician's office to another physician's office.

They were proposed as a mechanism for sharing clinical data that could lead to improved results. Initially, there was a great deal of interest in the concept, because it could help diagnose and treat patients. Over time, providers came to view the concept as something of occasional interest, but not part of the day-to-day activities of a practice.

What is needed is a real-time system that offers tangible benefits to both the provider and the patient as part of activities of daily practice.

As a result of federal legislation that created HIPAA, concern about confidentiality has become an issue. While it might be advisable to seek a legal opinion, the wording now used in political advertisements could serve a similar purpose by including the words "the patient has approved the request for a referral to you."

Setting up the referral service could certainly help regain patient confidence that the health care system is working on their behalf.

Richard Johnson is the retired president of TriBrook Health Care Consultants in Hinsdale, Ill. He can be reached at 630-655-0666.

Wesley Curry, now retired, was managing editor of book publishing for ACPE. He can be reached at 941-365-9292 or
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Title Annotation:Practice Management
Author:Curry, Wesley
Publication:Physician Executive
Geographic Code:1USA
Date:Jul 1, 2005
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