In healthcare, a referral is commonly defined as the act of directing a patient to a medical specialist. However, that definition is too simplistic. A better and more comprehensive definition is the act of directing a patient to a medical specialist when:
- The provider can identify the right specialist to whom to direct (refer) the patient.
- The provider can share clinical information with the specialist to whom they directed (referred) the patient.
We hear time and time again from healthcare providers and executives who believe they have comprehensive referral management capabilities, but in reality, don’t meet one or both criteria as defined above. Recently, a top hospital executive told us that “we already do referrals through our EMR system.” This statement exemplifies how many hospitals and provider networks fall short when it comes to referral management.
Let’s say Dr. Clark Kent, a hospital affiliated PCP on EPIC, needs to refer his patient to a cardiologist. Dr. Kent wants to refer his patient to Dr. Lois Lane, a non-hospital affiliated cardiologist also on EPIC. In this scenario, Dr. Kent only satisfies the second requirement of a referral. There are three mains reasons why this scenario does not meet the defined definition of a referral.
First, Dr. Kent has no idea if Dr. Lane is the right doctor for his patient. Dr. Kent likes sending patients to Dr. Lane because he knows her from his time at the Daily Planet. But, when recommending (referring) his patient to see Dr. Lane, Dr. Kent has no idea if Dr. Lane takes his patient’s insurance, has availability, etc. An EMR system does not help Dr. Kent identify the right doctor to refer his patient to. For example, Dr. Lane might not have availability for three months, but there are a dozen other hospital affiliated doctors that have availability within the next week. Similarly, Dr. Kent wants to ensure that he refers his patient to a doctor that takes their insurance, or in the case that the patient is going to an ambulatory facility, that the medical practice is in a location that is convenient for the patient. A referral management system will help Dr. Kent identify the right provider to refer his patient to.
Moreover, Dr. Kent wants to refer his patient to providers that are good at closing the loop and providing him information about the results of his referral. An EMR system does not help Dr. Kent identify the doctors who are good at closing the loop. Typically, providers who have referred their patients to their “friends” for years will quickly start sending referrals to other providers when they can easily identify different providers who are better at closing the loop.
Second, when Dr. Kent refers his patient to Dr. Lane, it is incumbent on the patient to then call and schedule an appointment with Dr. Lane. The EMR system does not allow Dr. Kent to book the referral appointment with Dr. Lane. When the burden of scheduling the referral appointment lies with the patient, only fifty percent of referrals result in a visit. However, that number jumps to around 80% (depending on the patient population) when the referral appointment is scheduled and booked by the referring doctor at the point of care. Furthermore, many doctors will tell a patient they need to see a specialist without actually providing any options, leading the patient to self-refer, which greatly reduces the likelihood the patient will follow through on the referral and increases the likelihood that patient will refer out-of-network (leakage).
Third, hospitals have an average of 16 different EMR systems. That means that even if Dr. Kent has identified the right provider to refer his patient to, it is likely that the provider operates on a different EMR. Conversely, if providers can only send referrals to other providers operating on the same EMR, they are severely limiting the referral network. A referral management system can serve to send clinical data across disparate EMRs and help hospitals create an integrated care network, which improves care coordination while reducing costs.
The key component to any medical referral is the decision/determination of who to refer the patient to. This is the area where most payer and provider networks fall short. On the bright side, the tools that help provider networks identify the proper provider for a referral are cloud- based, meaning they are quick and easy to implement and can provide an immediate impact on both patient outcomes and the bottom line.