Andrea King

Problems with referrals, says Marge Crossley, an administrator at a three-physician pediatric nephrologist practice in Philadelphia, begin when she tries to schedule an appointment. "Parents call and don't know what's going on," she says. "[Primary-care] physicians don't even tell the parents how quickly the child needs to be seen."

And once the appointment has been made, Crossley adds, "we have to fax and call right up to the day the patient comes in" for information like test results and blood work that are pertinent to treatment. "Ninety-five percent of the time, the referring physician's office doesn't send anything in," she says.

"I've had to drive across town to get X-rays, or run downstairs to get some information" when the patient arrives and the chart is incomplete, says Barbara Hale, a practice manager at a North Carolina neurosurgery practice. "If the patient shows up and the information still isn't there, we have to get on the phone again."

Patients themselves get on the line if they show up without a referral form at Greater Chesapeake Hand Specialists in Lutherville, Md. "We don't let the patient see the doctor without the referral," says administrator Patti Levin. "We usually call the patient ahead of time if we don't see [a form] in the chart, but if they show up without one, we invite them to call the primary-care physician to have it faxed over."

Does your practice experience these kinds of disconnects and delays related to referrals? You're not alone. According to a study published in May 2000 in the 

Archives of Pediatric and Adolescent Medicine

, improvements in the referral process can be achieved through better communication between primary-care physicians and specialists.

Researchers examined 963 referrals made from the offices of 122 pediatricians in a national practice-based research network. They found that only half of the primary-care physicians sent pertinent patient information to a specialist when making a referral, and just 39 percent of the pediatricians scheduled appointments for patients they were referring to other physicians. Researchers found that specialists were three times more likely to send results and recommendations when primary-care physicians personally scheduled patient appointments and sent relevant information. The lesson? Physician communication helps to smooth the bumps in the referral process.

Clearly, making a simple phone call to a specialist about the referral could save your patient an unnecessary trip. "Thirty-five percent of our patients can be better managed by a primary-care physician or a neurologist," says one neurosurgeon who works with Hale. "I would rather talk to [primary-care physicians] on the phone for three minutes before they send the patients over here. Sometimes, I have to send them back."

Hale says that after the referring physician's office calls to make an appointment, a clinician reviews the referral form to determine if neurosurgery is the best course of care, and if the patient's needs are urgent. "We always ask if patients need to be seen as soon as possible, or if they can wait for the first available appointment," she explains. "After the physician has seen the case, we sometimes have to go back and explain that the patient's needs are not urgent, or that it is an inappropriate referral."

To solve this problem, the practice began sending quarterly newsletters to 300 or so of the community's referring physicians. "In the newsletters, we publish different advances and techniques in neurosurgery, and when it's appropriate to send a patient to a neurosurgeon," says Hale.

The neurosurgeon in Hale's practice reports that the amount of inappropriate referrals has decreased as a result of their efforts. "I'm finding a lot more primary-care physicians are conducting magnetic resonance imaging tests (MRI) in conjunction with anti-inflammatory medications," he says. "They didn't do that before -- they just took the MRI and sent the patient to us." The surgeons are now receiving more physician-to-physician calls, which are helping to cut down on inappropriate referrals.

Some physicians are electronically "plugged in" to their patients' care. Saint Joseph's Hospital in Marshfield, Wis., in partnership with IDX Corp., has been developing Web-based software that allows referring physicians to access patients' records on a secure Web site. It's a smart solution for Saint Joseph's because the majority of referring physicians live more than 30 miles away from the hospital.

"We send admission notification [to the referring physicians], so they know their patient has been admitted to the hospital," says Lori Brenner, marketing manager for Saint Joseph's. "Physicians can log on from any computer that has Internet access. They can then see lab results, medications administered, operative notes, orders, radiology interpretations, and discharge summaries." Various security measures assure that physicians view only their own patients' records.

"We expect that all physicians send discharge summaries to referring physicians, but that doesn't always happen, so this allows the referring physician to have a little more control over the information," Brenner continues, emphasizing that the software is not meant to replace communication between physicians, but provide them with information when they want it.


"What's most important is that I will be able to get access to the patient's medical record before I get a letter from the attending or a discharge summary," says Pete Sanderson, a primary-care physician practicing in Stevens Point, Wis. He uses the program when he sends a patient with an acute problem, like a heart attack, to Saint Joseph's Hospital.

"They'll be discharged from Marshfield and I'll see them in my office prior to the time that the catheterization report will be back," he says. "It saves me the time I'd otherwise take to call the hospital, and [hospital] staff doesn't have to look up the report."

Brenner says that training time for the program is minimal. "I pay a visit to a physician organization, do a demonstration, and give them access [to the system]. Once we have their names, it takes about five minutes to set them up," she explains. Nearly 100 physicians affiliated with the hospital have access to the system, which Brenner hopes other local physicians will consider using.

Referrals can still be managed in an efficient manner without a software program -- by just using a telephone. "If you're going to refer someone, send us information and call, doctor-to-doctor," says Crossley.

This article originally appeared in the Spring 2002 issue of 

Articles

How to improve the referral process. Communication is key.

Retooling Referrals

It's been said that the way to a man's heart is through his stomach. True enough, a good meal can do wonders for a budding relationship. And how can physicians get through to one another to establish the ever-important referring relationship? One way may be through the palate.

When Reproductive Medicine Associates (RMA) opened a new office in Morristown, N.J., the physicians in the clinic invited all the OB/GYNs in the area to a wine tasting and presentation on their services. "We didn't have a track record with them, and we thought that the best way to tell them what we had to offer was in a social setting," explains Michael Drews, MD, one of the clinic's founders.

Physicians like the fertility experts at RMA depend upon referrals from community primary-care doctors for a robust patient base; developing and maintaining relationships with those physicians is essential for business. 

RMA took special care to open their doors in an area where there were no other fertility clinics, and the physicians sponsored the wine tasting to get their names known. The strategy worked: Drews reports that in the year and a half since the practice came to the Morristown area, the 12 physicians in the practice's three offices each see 20 to 40 new patients a month. 

The physicians at RMA took the common approach of starting their practice in an area where there was little competition. "We opened up several new offices, and each time before we chose a particular location, we wanted to find if that area was adequately served in our particular subspecialty," Drews says. "If there's an established practice in the area and you hope to open an office there, it's going to be that much harder."

Since referrals are generally tied to specific levels of service, physicians should clearly promote their professional focus and capabilities -- and be sure that they understand what other physicians have to offer so they can make the most appropriate referrals, according to Susan Miller, administrator for Family Practice Associates of Lexington, a seven-physician practice in Kentucky.

Build upon your relationships with other physicians, which may stem from medical school, a continuing medical education (CME) course, or other networking function. "Most physicians know each other through hospital affiliations," says Lorraine Lansing, a personnel manager for Stevens Healthcare in Edmonds, Wash. Some specialists offer seminars at local hospitals about a specific service they offer, or a new piece of equipment -- it's helpful to attend these types of events whenever possible.

One of RMA's employees goes "on the road" to deliver patient education pamphlets to referring physicians' offices, inviting them to special events, and informing them about RMA-sponsored weekly support groups for infertile couples. The practice also offers lunchtime educational seminars to the office staff of referring physicians, and provides opportunities for CME and social activities, like the wine-tasting event, to increase awareness among physicians in the area. 

"What matters most is that the specialist is easy and quickly accommodating," Miller says. "It's important that [the primary-care physician and the specialist] have the same insurance plan and the patient can see the specialist without too much delay." 

When a primary-care physician calls the office to make a referral, Miller instructs office staff to put the call through to the specialist immediately so the physicians can discuss the patient before the appointment is scheduled. 

Primary-care physicians give high marks to the specialist who provides timely and thorough communication about the care of the patient. Miller advises specialists to follow up with a brief, concise report that includes findings and recommendations. "Many specialists send eloquent letters or gifts," Lansing says. "We just need to know about the patient."

Drews says that he usually calls referring physicians to inform them of patients' progress. "We find that the [referring physicians] respond really well to a direct, personal approach," he says. He always tries to meet new physicians face-to-face "because it helps to associate a name with a face."

Whether by phone, letter, or e-mail, make sure to follow up with the correct physician if dealing with a large practice, to maintain a seamless continuity of care. "We don't want a patient getting referred back to a different obstetrician after she becomes pregnant," Drews says. 

The key to encouraging repeat referrals is the patient's positive experience with the specialist. "Once patients are sent to us, then they act as our emissaries," Drews says. "We hope that they will return to the physician and say that they were treated well." When this happens, referring physicians tend to have greater confidence making future referrals to the specialist.

If patients have negative experiences, referring physicians generally wait to see if a pattern develops. "Sometimes, people merely don't like what the doctor has to say," Lansing says, or there may simply be a personality conflict. Too many patient complaints, however, will likely have a negative impact on the flow of referrals.

Lansing adds that the information transferred to the specialist's office has to remain confidential. "Patients are assured of this," she says. Miller explains that there is an "unspoken sort of privacy" between the two physicians during the course of the patient's treatment. 

Although RMA counts on new business from local OB/GYNs, Drews says satisfied patients are responsible for about half of the practice's referrals. "We know that for most people, [fertility treatments] are something that they really would not go through by choice, and so we make the experience as palatable as possible," he says.

Patient satisfaction surveys are distributed to identify areas of the practice in need of improvement. "Everyone -- from the employees in the front office to those in the procedure room to those performing the procedures -- is extremely sensitive to the results of those surveys," Drews says. Staff raises are based on the results; the surveys are also used to assess the effectiveness of office operations.

To develop and maintain relationships with referring physicians, make sure they know who you are and what services your practice offers. Sponsoring special events can certainly be a plus, but the real key is the quality of care you provide. Referring physicians will gain confidence when their patients report back with a positive experience, and are apt to send more new patients your way. 

This article originally appeared in the March/April 2002 issue of 

Learn how to work better with and market to referring physicians