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  • David Y. Ting, MD, FACP, FAAP


Hello, welcome to our third and final installment in a series looking at the risk when a specialty referral fails in the ambulatory setting. According to estimates, as many as half of specialty referrals are not fully completed. In a study of medical malpractice cases asserted in the Harvard system between 2006 and 2015, 46 cases involved referral breakdowns, with an incurred cost of $11 million. In 83 percent of those cases, the harm to the patient was categorized as severe.

In Late 2017, Harvard’s medical malpractice and patient safety company, CRICO, published a white paper in conjunction with the Institute for Healthcare Improvement. It is called, “Closing the Loop: A Guide to Safer Ambulatory Referrals in the Electronic Health Record Era.” To support release of that guide, the two organizations hosted a webinar at the beginning of 2018. One of the presenters was Dr. David Ting, an internist and pediatrician in Boston, and the Chief Medical Information Officer for the Massachusetts General Hospital Physician Organization. Dr. Ting also co-authored the closed loop referral guide, and he joins us now.

Q) Thank you for being here David.
A) Thank you so much. It’s a real privilege and a pleasure to be here.

Q) What’s happening to patients when this goes wrong?
A) Yeah, it’s really concerning when the referral loop is broken because at any point along that closed loop process, patients and information and patient care can fall through the cracks. And so to give you some examples, right up front when the decision is made to refer the patient to the specialist’s office, there’s a communication gap that can happen where the pass-offs of information from the referring doctor to the consultant doesn’t happen, or it’s not clear to the referring physician or to the patient whether it’s the patient’s responsibility to arrange the appointment or whether it is the expectation that the specialist’s office will contact the patient. When those expectations aren’t set right up front, even the simple matter of having the patient connect with the specialist can be a break point. At other points in the loop, having the patient schedule that appointment and then show up becomes another point of potential missed opportunity. So, for instance, who’s tracking whether or not the patient shows up at the specialist’s office? And if the patient fails to show up for that appointment, whose responsibility is it to then follow-up and ensure that the patient is getting the care that they need? Once the patient has been seen, how do we ensure that the appropriate information and the right kind of information is passed from the referring doctor to the specialist? How can we ensure that the specialist has, not only the amount of information, but understands what the question is that’s being asked by the referring physician? And then after the patient has been seen, how do we ensure that the results of that consultation are communicated back to the referring physician, communicated back to the patient, and communicated back to members of the team or the patient’s family who need to then act on those recommendations? And then finally, how do we ensure that those recommendations are actually executed on? So you can imagine, all along that loop of the referral process there can be break points, and those are the sort of challenges that we as clinicians and as health care organizations are very eager to try to solve and improve.

Q) Behind all of those steps and all of those needs that you were talking about, you’ve probably seen this reflected some malpractice cases, where the patient is sitting in the specialist’s room and the specialist and the patient don’t seem to know why, and they are doing screening things when they should be diagnostic things, and all that kind of stuff.
A) Absolutely, and we know from the work of CRICO, as a for instance, that the vast majority of malpractice cases and claims come in the ambulatory space and a big proportion of those have to do with referrals and the lack of proper communication within that referral process so it’s a real concern.

Q) How did you set out to understand what it is that has to happen to change it? I mean, everybody in practice probably has a theory or an idea. This was a project that really sought to understand the problem so that you could come up with solutions that would actually work to fix the problem, right?
A) Absolutely and, in fact, I’m so grateful to CRICO as well as IHI/NPSF for bringing together a group of experts from across the country to look at this question. So, as you know, last summer a group of about two dozen folks who are very interested and committed to improving the referral process were able to come together in a collaborative way to talk through what actually are the steps in the referral process. And then with each of those steps can we do a failure mode analysis to identify how things can break at each point along that referral loop? And then once we’ve identified the failure modes, how can we address those using the available technology in today’s EHRs, but also to work with vendors to discover ways, and maybe collaborate on ways, to improve today’s EHRs to make the referral loop even tighter?

Q) You have been very close to trying to understand the problem and appreciate what the problem is. You have been looking at malpractice claims and things like that and trying to figure out solutions. Do you think the typical day-to-day practitioner understands their vulnerabilities here, understands what the problem is, that there even is one, or how to do anything about it?
A) Oh absolutely, absolutely. Given the level of anxiety among clinicians about medical malpractice risk, I think it’s very clear that practitioners are worried about patient care falling through the cracks, about patients not getting the appropriate studies done, not getting the appropriate workup. The anxiety around medical malpractice? That’s very real. And you add to that the concern about patient safety and about the quality of patient care, that also is very real to the frontline physician and provider. And the frustration, of course, is when there’s inconsistency in the referral process. And I’m talking about inconsistency between institutions, but even within an institution there’s inconsistency from one practice to another and from one department to another. And when there aren’t the consistencies in process and expectations all through the referral loop, that engenders a tremendous amount of frustration and anxiety on the part of the clinicians right on the frontline. Because you can’t know to trust that when you send a patient to a colleague to be evaluated that the patient will actually get all the appropriate care that they need, and there’s almost nothing more unsettling than that as a frontline clinician.

Q) I understand. What do you think, or what do you hope will be the outcome of publishing and promoting these guides?
A) Ah, so there are a couple of different levels of hope that comes out of this work. On the one level is raising the awareness that, first of all, closing the referral loop is a patient safety priority area and should be a priority area. And, related to that closing the referral loop can be done. And the second hope, is that it can be done if everyone gets on the same page about setting expectations, understanding best practices, and creating processes, technologies, and etiquette that promote closing that referral loop. And so my second hope is, that by broadcasting the white paper at a national level that we actually create a culture in our country around the referral process, so similar to the way that when you go into any OR, there’s now an expectation around the use of checklists for patient safety, or if you go into a laboratory environment there’s an expectation around certain quality controls around labs and lab results, and closing the lab test result loop is more and more of an expectation. My hope is that as a health care culture, we will begin to think about the referral loop with the same reflex of closing it the right way with expectations set both on the referring physician side and the specialty consultant side. That would be a big win. And I think by so doing, we really have an opportunity to improve the way patients are cared for throughout the country.

Q) Thank you David. Dr. David Ting, an internist and pediatrician in Boston, is the CMIO at MGH Physician Organization. Dr. Ting also co-authored the guide, “Closing the Loop: A Guide to Safer Ambulatory Referrals in the Electronic Health Record Era,” which is available through the Institute for Healthcare Improvement web site, www.ihi.org.


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