North American health care jurisdictions have many features that contribute to fragmentation of care: independent practices, limited use of electronic records that transcend the care continuum and physician reimbursement that fails to recognize efforts to coordinate care. More recent developments, such as health plan physician networks and the separation of primary care from hospital care, have tended to erode personal relationships between primary care physicians (PCPs) and their specialist consultants and the institutions where patients get care. As a consequence, consultants frequently complain about the poor quality of information sent by referring clinicians and the inappropriateness of many referrals, while primary care physicians often receive no information back from consultants, and are not notified when their patients are seen in an emergency room (ER) or admitted to the hospital. These failures in communication and care coordination—typically referred to as fragmentation— can have devastating consequences for patients.
This lack of communication between PCP and consultants leads to declining care coordination and hence poorer quality of care. One of the key areas where this communication breakdown occurs is in the connectivity of PCP’s and consultants. On the one hand, PCPs need to be sure that consultants know the reason for a referral and have the necessary information to provide optimal service. On the other hand, consultants must provide information back to the PCP that addresses their questions and concerns for follow-up care. And providers should keep patients informed and confident that all the providers involved are communicating with each other.
The presence of an intelligent electronic referral (e-referral) system can help ensure that this critical information flow occurs in a timely way. E-referral systems can incorporate agreed upon guidelines for referrals and transitions that prevent unnecessary ones and assure that consultants and PCPs get the information they need to appropriately progress the patients’ care plan.
High-quality referrals and transitions depend upon every provider responsible for the patients’ care having the information they need when they need it. The requisite information of course includes essential data about the patient and their treatment plan. The essential information should also include the test results needed by the consulting specialist to complete their consultation. Referring patients without test results deemed necessary for an adequate consultation is a common reason that referrals are refused, duplicate testing is done, or consultations take multiple visits. Which tests are necessary may well vary among physicians in a given specialty, so they need to be discussed as part of the agreement process.