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  • Tejal Gandhi, MD, MPH
  • Luke Sato, MD


In any complex medical system, malpractice cases can arise from failures in the referral process. Typically these are situations in ambulatory care, where the doctor recommends that a patient see a specialist, but the specialty referral either doesn’t happen or nobody acts on the result.

By some estimates, as many as half of specialty referrals are not fully completed. Beyond inefficiency, mishandled referrals represent mistakes that can hurt and kill patients through a delay in diagnosis or mistreatment. Between 2006 and 2015, 46 malpractice claims in the Harvard system involved referral breakdowns, with an incurred cost of $11 million. Eighty-three percent of those cases involved a high severity of harm to the patient.

In late 2017, the Institute for Healthcare improvement—IHI—joined with CRICO, Harvard’s patient safety and malpractice company, to release a new tool, called Closing the Loop: A Guide to Safer Ambulatory Referrals in the Electronic Health Record Era.

Today we start a multi-part series on the topic of reducing mistakes in referral management, by looking more closely at the nature and the scope of referral problems. In a little bit, we’ll talk with the Chief Medical Officer for CRICO and Assistant Clinical Professor of Medicine at Harvard, Dr. Luke Sato... But to start us off is the Chief Clinical and Safety Officer for IHI, Dr. Tejal Gandhi.

Tejal, thank you for joining us.

Gandhi: Thanks so much for having me.

Q) Now, when we talk about referral problems, we’re really looking at diagnosis errors, right? Can you give an example?

Gandhi: Absolutely. I mean there's definitely a lot of inefficiencies too, but there can be very significant breakdowns that occur in this process that can lead to harm and death. So, an example would be a person is referred to a breast surgeon because of a breast lump but doesn’t end up going to the surgeon for a variety of reasons and then a year later comes back with advanced breast cancer. And so the referral system and process has many places where it can break down and things can fall through the cracks, and that has been a significant contributor to these missed and delayed diagnoses. So that’s the problem that we are trying to solve by trying to think about what would an ideal best practice be for a referral process that was really highly reliable, where things don’t fall through the cracks, and where can ensure that if a patient needs a referral, they get that referral and then the information from that referral is communicated to everyone who needs to know about it.

Q) One of the messages that we’ve been telling people for a very long time is that it’s not just up to the patient, and if the patient doesn’t show up for an appointment, you can’t say, Well gee, the patient didn’t show up for an appointment, not my fault.

Gandhi: Correct and I hear a lot of that feedback as well in this space. I think the key thing that we need to think about is what’s the right thing to do, one, and what are the reasons that patients may not be going to appointments is the second thing. Because there are often very good reasons why a patient may not have gone to the appointment, where they couldn’t get an appointment or they had no transportation to go to the appointment, or you could name a whole bunch of other issues. They didn’t realize it was an important appointment and they just deprioritized it because there wasn’t good communication to say this is really important.

So I think we need to understand the reasons why patients aren’t doing some of the things we’re recommending and really do a better job of engaging patients and making sure we have a shared care plan that everyone is in agreement with. And we talk about patient engagement all the time in patient safety as critical to advancing patient safety and this is one of those areas. So I think we need to have a shared responsibility, and if I want a patient to go see a surgeon because of a breast lump, it seems like as a primary care doctor, you should at least know if the patient went or not. If the patient chooses not to go and you have a shared decision-making conversation and they say, 'no, I’m not going to go,' that’s one thing. But when it just sort of falls through the cracks and no one realizes it didn’t even happen, that’s where we run into problems.

Q) This issue is really a hallmark of outpatient ambulatory care. I mean, if you’re inpatient, you order tests and you want the patient to see a specialist, they are laying down on a gurney and you’re going to have that done for them, but in the outpatient setting it’s different, isn’t it?

Gandhi: It certainly is. I mean, it sounds very simple; we just need to close the loop on referrals. It turns out this is highly complicated. Just thinking about scheduling and scheduling across providers that may not be in the same system. How do you make the appointment? Do you have the patient make the appointment? How do you make sure if the patient makes the appointment, that you know they made the appointment? All of these little things turn out to be very complicated. Similarly on the communication going to the specialist and back, even within a single system, sometimes there’s communication breakdown. And then imagine the complexity when, again, it’s across systems or in private practice where it’s two separate practices. There are just lots of places where things can break down. So it is reflective of the broader ambulatory space, which is highly variable and complicated.

Q) Now you’ve identified nine steps in this guide and we can describe the steps, maybe at a higher level, maybe you can say something about what you came up with and how you came up with it.

Gandhi: So the way we created the framework in the report was really looking at the existing literature on the referral process, referral breakdowns, what we know about where things break down. And so we did that literature scan, and then we convened an expert group of researchers in the referral area, as well as frontline clinicians, folks that represented industry and the vendor community, folks that represented physician and nursing groups in the ambulatory setting. We brought everybody together to really think about what are the key steps in a closed loop referral process and then what are the key breakdowns in each of those steps, and what are potential solutions? And the solutions were looked at both in terms of what could an electronic health record do to help as a solution, and what can a practice do? Because we think technology is going to be a really important way to improve this process, but it’s not going to be the only way and it’s not a panacea. Because if you have a really terrible process in your practice, just adding technology to it is not going to help.

Q) What do you think is the most important takeaway?

Gandhi: Well, I think the takeaway is the referral process is very complicated. There’s lots of opportunity for error to occur, and it does lead to patient harm. And it’s been an area that probably hasn’t gotten the attention that it merits.

Q) Great. Thank you. Dr. Tejal Gandhi, Chief Clinical and Safety Officer at the Institute for Health Care Improvement, which, together with CRICO, has released a guide on how to close the loop on ambulatory referrals. It can be found on the IHI.org web site.

And now joining us is Dr. Luke Sato. Dr. Sato is Assistant Clinical Professor of Medicine at Harvard Medical School, and Senior Vice President and Chief Medical Officer for CRICO.

Q) Luke, thank you for joining us.

Luke Sato: My pleasure Tom.

Q) Problems in managing referrals have been around forever it seems, and people may have thought that the introduction of electronic health records could have solved it all by now. Of course, that’s not how it plays out is it?

Sato: Well CRICO has been interested in the referral process for quite a number of years. It was actually in 2009 when we started to be very much interested in this process from the context of addressing missed and delayed diagnosis. Initially, I think there had been an expectation that electronic medical records would help address some of the issues, but I think as people started to implement them, we found out that the actual process of implementing varies from organization to organization. Plus, what is actually within the EMR itself varies between the vendors and the types of tools they are. And we found out that despite implementing electronic medical records, there were still issues that were emerging that were not being addressed, particularly from a malpractice perspective.

Q) Dr. Gandhi said that referral management is complicated, so some people might even be surprised to think that there are nine steps for every referral. Can we go over them very quickly here?

Sato: Sure. So the nine steps that we came up with derive from the gaps that we were experiencing in the care process as we were analyzing our malpractice claims. So overall there are nine steps. The first step is where the primary care physician orders the referral. The second is the primary care physician communicates the referral to a specialist. The third step is that the referral is reviewed and authorized. The fourth step is the appointment is scheduled. The fifth step is that the consult occurs. The sixth step is the specialist communicates the plan to the patient. The seventh step is the specialist communicates the plan to the primary care physician. The eighth is the primary care physician acknowledges receipt of the plan, and the final ninth step is the primary care physician communicates the plan to both the patient and to the patient’s family.

Q) We have this joint effort between CRICO and the Institute for Health Care Improvement and developed and promoted this Closed Loop Referral Guide. There was a webcast at the beginning of the year. How do you envision the guide being used in practice and what do you hope the impact will be?

Sato: I think there are multiple places where we see the guide being utilized. One is obviously at the practice level. If each provider understands where the potential gaps are, I think it would be helpful to set up a process within their own practice to address some of the gaps. So, having clarity around the accountability of who is supposed to be doing what and the roles and responsibilities is a critical element.
On the other hand, there are things that occur at the organization or at the systems level—perhaps it’s built in as a functionality within the electronic medical record—and we would be working with the institutions to make sure that those elements are, for example, embedded. So if a patient does not show up to an appointment to a specialist, then there’s a mechanism within the electronic medical record system that alerts the primary referral physician that the patient did not show up. So there are things that I think are, responsibility-wise, split from what the practice or the individual provider can do versus what the hospital or the system can do.

I think in general, it’s very promising that now within the organizations, as well as within the quality and safety community, there’s been a tremendous amount of interest growing in addressing referrals. And to me that’s an exciting aspect, and we hope to be able to work with all of the stakeholders that are involved in this process to help address this risk area and move it forward in terms of making it a lot safer and improving the quality of care for our patients.

Q) Well thank you. Dr. Luke Sato is Assistant Clinical Professor of Medicine at Harvard Medical School and Vice President and Chief Medical Officer for CRICO.

Join us on our next podcast for our interview with Dr. Hardeep Singh from the DeBakey VA Medical Center in Houston. Dr Singh helped co-author Closing the Loop, Safer Ambulatory Referrals in the EHR Era. He has also been a leading researcher in patient safety, health IT, and reducing misdiagnosis. So until then, for CRICO, I’m Tom Augello.


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