Recent research reveals significant communication gaps between healthcare providers in different locations caring for the same patient. It has been estimated that nearly half of physicians in the United States cannot share clinical information such as diagnostic test results and patient medication histories with clinicians outside of their practices.1,2 Other research suggests the majority of primary care providers do not hear back from specialists whom they have referred a patient to within a week after the specialist consult.2
Given these challenges, Sutherland and colleagues recently published a study looking at the development of trust between members of interdisciplinary teams caring for patients with diabetic foot ulcers (DFUs).3 Compiling information gathered from 39 health-care providers in Wisconsin, the researchers found that proximal location and a shared electronic health records (EHR) system were key factors in facilitating communication between interdisciplinary providers. Alternatively, the study authors noted that “distributed” health-care workers from different locations and without a shared EHR system often had to rely upon individual initiative to follow up on referrals and consults. Specifically, Sutherland and coworkers noted that “Few effective tools existed at the level of interprofessional collaborations, teams, or broader healthcare systems to support trust between distributed healthcare workers.” 3
Acknowledging incompatibility issues that thwart EHR communication between providers at different facilities, Alissa Redding, DPM, says referral communication is often dependent on old-school approaches.
“Being in a rural hospital, I am heavily reliant on records faxed or mailed with referrals or patient visits, and I try to do the same when referring patients outside the clinic,” notes Dr. Redding, who is affiliated with the Glacial Ridge Health System in Glenwood, Minn.
While he is usually on the receiving end of referrals as a vascular surgeon, Issam Koleilat, MD, says it is common for his office to have to call and have relevant clinical documents faxed over for new referrals. That said, he points out that integration within the same EHR software is not always a panacea.
“… Sometimes, I have to open multiple software applications to find the information I need, and sometimes I have to track it down,” acknowledges Dr. Koleilat, who is affiliated with RWJ Barnabas Health in Toms River, N.J. “At times, when I need to look at the actual images of a test the patient had outside of our hospital system, we have to actually request that the images be burned to a CD that can be mailed to us. This delays care or results in multiple visits and multiple copays/increased cost.”
Meghan Brennan, MD, MS, a co-author of the aforementioned study, says providers who reach out on referrals for a brief phone conversation tend to provide great care. She says this communication can go a long way toward ensuring that little is “lost in translation” when information needs to be shared across systems. From a systems standpoint, Dr. Brennan advocates a referral checklist that outlines key information to be sent with the consult request. Additionally, Dr. Brennan says consulting physicians need to keep in mind that the person sending over the referral is likely an administrator or scheduler with less medical knowledge, so it is important to clarify what information is needed to facilitate the referral and best serve the patient. She says one of the biggest areas to improve upon is simply communicating when the consult is scheduled to take place.
“As consultants, we need to get back to referring offices to let them know when the patient is scheduled to be seen,” maintains Dr. Brennan, an Assistant Professor in the Division of Infectious Disease within the Department of Medicine at the University of Wisconsin School of Medicine and Public Health. “I was struck by how many primary care providers keep lists of patients they referred to specialists and are trying to keep track of when the patient was scheduled to figure out if the timing was appropriate, and when to look for the consult note. We could make it so much easier for them simply by having our administrators or schedulers communicate when the consult is scheduled to occur.”
While the study emphasizes the importance of co-location and a shared EHR in promoting interdisciplinary provider communication and trust, these factors may also have a direct impact on the quality of patient care.3
“Co-location and a shared EHR really do help facilitate patient care,” emphasizes Dr. Brennan, a member of the Infectious Disease Education Committee and the Preventing Amputations in Veterans Everywhere (PAVE) Committee at the William S. Middleton Memorial VA Hospital in Madison, Wis. “From the standpoint of an infectious disease doc, it’s critical to know how the bone samples from a minor amputation were collected. A lot of times, it is difficult to figure out if a culture was sent from a proximal (clean) sample or a distal (dirty) sample. Being able to easily track down and talk to the surgeons who did the procedure really helps clarify whether that patient has residual osteomyelitis or not.”
“I have had the most success treating patients with DFUs when they come from internal referrals, whether they come from family medicine, internal medicine or a wound care nurse at my facility,” notes Dr. Redding. “With other providers in the area, we all try to communicate via phone or fax to get pertinent information to the team. So, co-location is a big factor for me for continuity of care.”
Dr. Koleilat says the shared EHR is ideal for timely, efficient interdisciplinary communication in limb salvage cases.
“It just makes everything immediately accessible, and you don’t feel like you need to call people just to track down what the plan is for a wound,” adds Dr. Koleilat, a Fellow of the Society for Vascular Surgery and the American College of Surgeons. “You can even send messages within the EHR with the chart attached, which makes it easy for people to review the record and answer questions. Co-location is nice and does streamline visits for patients, but I personally value the shared EHR a little more for those reasons.”
When it comes to working with providers from other disciplines outside of one’s practice setting, Dr. Koleilat emphasizes good communication with the primary or referring provider as that person may be the one coordinating the patient’s care. Accordingly, this communication may cover new medication prescriptions, avoiding potential drug-drug interactions with current medications, or the timing of surgical procedures for patients who may be on dialysis, according to Dr. Koleilat. The more specific the communication between the referring doc and the specialist, the better.
“ … To discuss findings, the thought process and plans moving forward, that builds good trust,” maintains Dr. Koleilat. “It just shows that the person on the other end is putting thought and humanity into the patient’s care.”
“I try to be as specific as possible when sending referrals,” concurs Dr. Redding. “This gives the clinician an idea of the backstory and he or she can let me know if this is something that can work for him or her. Likewise, I greatly appreciate when referring providers can tell me a general reason for the referral, be it a DFU, possible fracture, plantar fasciitis, etc. This is in addition to timeliness and being accessible for patient or clinician questions or concerns.”
Advice for New Clinicians on Developing Referral Networks
For new physicians just getting into practice and seeking to establish an interdisciplinary referral network, Drs. Brennan and Koleilat recommend giving out the cell phone number liberally.
“I doubt they will be inundated with calls, but colleagues will really appreciate the gesture and have their number when they need it,” adds Dr. Brennan. “Also, it is hard not to reciprocate. New clinicians will likely end up with some good contacts too.”
Referencing what one vascular surgeon referred to in the study as the three As (affability, availability and ability), Dr. Koleilat says this kind of accessibility has been informally passed down from generation to generation of surgeons.3 He suggests sending a note or letter to the referring physician with the office evaluation attached, and having an easygoing, cooperative demeanor.
“You could be the most gifted surgeon of all time but what people really care about from day to day are the kindergarten things: ‘shares toys’ and ‘plays nice in sandbox.’ If you can do those two things, people will work with and help you,” notes Dr. Koleilat.
For new practitioners, Dr. Brennan recommends taking advantage of grand rounds opportunities at local hospitals.
“A grand rounds venue — especially engaging an audience outside your specialty — is a way colleagues can get to know you and your scope of work,” says Dr. Brennan.
In addition to sending office notes and operative reports (with the patient’s permission) to the referring doctor, Dr. Redding says another key for new physicians is to be open to consults, even if they are simple or not particularly exciting.
“This builds trust and a reputation of reliability as well as a steady referral source and possibly more interesting consults in the future,” suggests Dr. Redding.
- Davidow SL, Sheth J, Sixta CS, Thomas-Hemak L. Closing the referral loop: improving ambulatory referral management, electronic health record connectivity, and care coordination processes. J Ambul Care Manage. 2018;41(4):240-249.
- Doty MM, Tikkanen R, Shah A, Schneider EC. Primary care physicians’ role in coordinating medical and health-related social needs in eleven countries. Health Affairs. 2020;39(1):115-123.
- Sutherland BL, Pecanac K, LaBorde TM, Bartels CM, Brennan MB. Good working relationships: how healthcare system proximity influences trust between healthcare workers. J Interprof Care. 2021; June 14;1-9. doi: 10.1080/13561820.2021.1920897. Online ahead of print.