According to a new study appearing in the February 2010 issue of the Journal of Evaluation in Clinical Practice (available on line), only 71 percent of patients age 65 or older who are referred to a specialist are actually scheduled to be seen by that physician. Furthermore, only 70 percent of those with an appointment actually went to the specialist's office. Thus, only 50 percent (70 percent of 71 percent) of those referred to a specialist had the opportunity to receive the treatment their primary care doctor intended them to have, according to the findings by researchers from the Regenstrief Institute and the Indiana University School of Medicine.
From the study:
Better information systems are likely to improve several aspects of care. For clinicians, systems can be designed to identify multiple orders or appointments. Systems can provide more effective training about referrals, more complete clinical information and better tools for decision support and documentation.
Communication systems are also critical for effective referral. Systems for electronic messaging between primary- and secondary-care clinicians can be especially useful. Walter Reed Army Medical Center implemented an 'Ask a Doc' system based on electronic mail, with average response times to specialty consultation of less than 1 day. Although messaging systems help, referrers and specialty consultants benefit from talking personally and agreeing on goals.The Institute of Medicine, in its seminal report "To Err is Human," defines a medical error as a "wrong plan" or a failure of a planned action to be completed.
"Patients fail to complete referrals with specialists for a variety of reasons, including those that the health care system can correct, such as failure of the primary care doctor's office to make the appointment; failure of the specialist's office to receive the request for a consultation—which can be caused by something as simple as a fax machine without paper – or a failure to confirm availability with the patient," said Michael Weiner M.D., M.P.H., first author of the study.
"There will always be reasons – health issues or lack of transportation, for example – why a referred patient cannot make it to the specialist he or she needs, but there are many problems we found to be correctable using health information technology to provide more coordinated and patient-focused care. Using electronic medical records and other health IT to address the malfunction of the referral process, we were able to reduce the 50 percent lack of completion of referrals rate to less than 20 percent, a significant decrease in the medical error rate," said Dr. Weiner.
The JECP study followed 6,785 primary care patients seen at an urban medical institution, all over age 65, with a mean age of 72. Nearly all (91 percent) of the patients were covered by Medicare.
"This is not necessarily the fault of patients or doctors alone, but it may take both working together – along with their health system – to correct this problem. Our study highlights how enormous a problem this is for patients who were not getting the specialized care they needed. Although our findings would likely differ among institutions, unfortunately overall trends are similar in other parts of the country" said Dr. Weiner.
Dr. Weiner is director of the Regenstrief Institute's Health Services Research Program, director of the Indiana University Center for Health Services and Outcomes Research, and director of the VA Health Services Research and Development Center of Excellence on Implementing Evidence-Based Practice at the Roudebush VA Medical Center.
Co-authors of the study are Anthony J. Perkins, M.S., of the Regenstrief Institute and the IU Center for Aging Research, and Christopher M. Callahan, M.D., a Regenstrief Institute investigator and Cornelius and Yvonne Pettinga Professor in Aging Research at the IU School of Medicine. Dr. Callahan is founding director of the IU Center for Aging Research.
This study was supported by the National Institute on Aging.
The Regenstrief Institute and the IU School of Medicine are located on the campus of Indiana University-Purdue University Indianapolis.