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  • Hardeep Singh, MD, MPH


Hello, and welcome to Part II of our 3-part series on fixing problems in the referral process. We are following the efforts of the Institute for Healthcare Improvement and CRICO to create guidance for primary care and specialty practices. “Closing the Loop: A Guide to Safer Ambulatory Referrals in the Electronic Health Record Era” was jointly released by IHI and CRICO in late 2017.

The tool works through nine steps in the referral process, from a PCP recommending a specialty referral, through that referral appointment, back to the PCP and, finally follow up with the patient. Incorporating literature review and new analysis of medical malpractice claims and other data, the authors hope individual practices and institutions will use the Guide to make their referrals more reliable and reduce mistakes.

Among the researchers and experts on the panel that developed “Closing the Loop…” is Dr. Hardeep Singh, who joins us now. Dr. Singh is a general internist and renowned patient safety researcher from the Debakey VA Medical Center in Houston, Texas.

Q) Dr. Singh thank you for being with us…
A) Thanks for having me.

Q) You’re very welcome. What’s the nature of the problem you’re trying to address?
A) So electronic referrals, I mean, one would imagine that we’ve improved communications through use of information technology and moving information from point A to point B and it has become easier. But even in the age of electronic referrals, we still lose information—some of our work shows about 6–7% communication breakdowns between primary care and specialists. So this is an important problem that we need to solve. Despite the use of information technology we’re still losing some of these referrals.

Q) What happens as a result of this? What can happen to patients?
A.) So because of breakdowns in communication between a generalist and a specialist, for instance, there could be delays in care, missed care, delays of diagnosis of cancer could happen. In fact, any delay in care or procedure or treatment because of breakdowns in communication between primary care and specialty care. It’s an important area that we need to address.

Q) In your own experience and talking to people about this issue, do you think that most doctors and nurses in practice understand the issue and the vulnerability? Do they know how to fix it?
A) Yes, one of the things we recommend in this tool kit is start to measure and track how often some of these referrals are getting lost, and it could be an eye opener. So a lot of people think things are working smoothly but then you realize once you track things, oh, that actually never reached the other side or I never heard back from that patient; it’s been three months. So I think once you want to get sort of the seamless flow of information between several fragments of our health care system to work, and you figure out the information is not moving, it’s an eye opener. So yeah, for sure, I think people are going to need to do some of the tracking, do some measurements, figure out what the gaps are and those gaps are really eye openers for improvement.

Q) Traditionally, has this referral process been kind of an office management issue at some level? Does your work here recommend more engagement in the process of that referral from the clinicians themselves?
A) Yeah definitely. I think not just engagement from the clinicians themselves, but also of the office staff —engagement from the nurses, office manager. Some people are needed who can track some of these referral processes. Some of this measurement that we recommend tracking process. It’s a big deal. We need support as a physician, for instance, if I’m in primary care, I’m going to need my office staff to help me sort of track some of these referrals. So for sure, I think it’s a team base.

I think it fits very nicely with the medical home concept where it’s just not the solo practitioner, but a team that is around the practitioner trying to help them do their work. But at some point in time I think it’s also an organizational responsibility. So if it is a multispecialty clinic, it’s just not about the docs or the providers in the multispecialty clinic but also sort of the leadership of that multispecialty clinic. What can they do? How can they get engaged in doing some of the steps? How can they provide the support that’s needed to make sure that the loop on the referral process is closed. This is just not like old single practitioner issues. We need engagement from everybody, not just the frontline staff and administrative staff but also the leadership of the institution in the way this work is being done.

Q) What do you hope will be the outcome of publishing and promoting this guideline?

A) These are recommendations. What we hope is people will find this information useful. We’ve now got information technology and we’re trying to figure out how this technology supposed to improve what we do, but people are sort of finding that we’ve got more technology now, but we’re not seeing the improvements that we needed.

And I think what the guide does is it sort of walks you through the processes that are needed, at least for the referrals, as to how you could make sure that the process is safer and is more closed looped. Going through the guide requires time and investment of some sort of a resource to understand what we needs to be done. But we have a pretty good business case for this because I think having a better process which is more efficient, safer for patients, more higher quality is the business case. And imagine, if you have appropriate referral requests between PCPs and specialists, it will be less frustration when you don’t keep hearing from the specialists about what happened to your patient, which I’m sure PCPs have had issues with before.

And the problems with communication have been both sides. It’s been PCP to specialist and again specialist back to PCP as well. Ultimately the products of these recommendations are reduced administrative burden and we know how much burnout internally there is right now. So I think this is a good way to think about how can we improve experience, reduce burden—and ultimately CRICO is known for this—but maybe there will be fewer malpractice claims when we have better recommendations. It’s just not about increasing the productivity and experience from these referral processes but also having fewer malpractice claims and having safer care and higher quality care.

Q) All right, thanks again. I really, really appreciate your time.
A) Thank you. This has been good.

Q) Dr. Singh is a researcher and general internist at the Debakey VA Medical Center in Houston. He is one of the lead authors of the new tool for safer, more reliable specialty referrals, called “Closing the Loop: A Guide to Safer Ambulatory Referrals in the Electronic Health Record Era.” It is co-sponsored by the Institute for Healthcare Improvement and CRICO, the insurance program and patient safety provider for Harvard’s medical institutions and affiliates. The guide can be found at the IHI website, www.IHI.org. Just search the phrase “Closing the Loop.”
I’m Tom Augello.


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