Increasing Patient Involvement in Referrals to Specalists

Patients frequently do not know why they were referred to see another doctor. Involving patients in the referral process can increase patient involvement, reduce no-shows, and improve consultative medicine.

Why Am I Here?

Many patients first discover they were referred to see a specialist when a letter arrives in the mail with an appointment date and time.

Patients can often guess why they were referred when they both understand what the specialist does and have symptoms that fit.  For instance, getting a letter to see a cardiologist and having symptoms of chest pain.

However, patients often do not know what the specialist does or why they were referred there.

I asked every new patient I saw in rheumatology clinic if they know what a rheumatologist is. Practically nobody did.

Referrals are also a mystery to patients with diseases that presents on lab-work or imaging prior to symptoms.  Patients in nephrology or hematology clinic often report never knowing before that they had a problem with their kidneys or blood.

If an abnormality is seen on imaging or screening and patients are referred to a surgeon or Cancer Care, this causes concern.

Benefits of Joint Patient-Physician Consult Referrals

First, it is the right thing to do - involving the patient.

Second, it likely would reduce missed clinic appointments. If you know why you are going to see a doctor, you are more likely to attend.

Third, it is an opportunity for patient education.

Fourth, it helps the specialist clinic ensure the patient's questions are addressed.  If they know ahead of time what the patient's concerns are, they can arrange to address these questions deliberately.  Either with the doctor, nurse, or respiratory therapist, or by handouts, websites, or videos. 

Fifth, many referrals generate questions and cause anxiety in patients. Such as an unexpected letter from Cancer Care.  If the appointment is still a ways off the clinic can call the patient to help re-assure and answer preliminary questions. This would prevent the standard situation of two months (or 6 months) of sleepless nights as the patient waits for their appointment.

Sixth, it is not uncommon for the patient to arrive (and wait) in clinic, only to be told they don't need to be there.  This happens when the patient has already seen a physician from that specialty.  For instance, two referral letters may be sent - such as one from the Family Physician to a neurologist, and the second by the emergency department to another neurologist.  I know of a patient that received four letters to four different hepatologists.

Another way (quite common) is for the patient to have been hospitalized for the condition before they were seen by an outpatient specialist. In hospital they may be treated by a gastroenterologist, and there is no reason to keep their original outpatient appointment with a different gastroenterologist .  If the patient is aware why they have an appointment, they would be able to suggest canceling appointments they suspect are no longer required.

Seventh, referral letters have mistakes.  Either the information about the patient is wrong, or the referral is to the wrong doctor. This happens when two physicians have the same name.  If the patient knew why they were referred, they could figure out if its to the wrong doctor. I've found physicians with the same name are often related, and one is a surgeon and the other is not.

Implementation via the Electronic Health Record of Joint Physician-Patient Referral Letters

I suggest:

1.  When patients are referred to another clinician they are able to view the entire referral letter via the electronic patient portal.

2.  The patient portal has an information section that explains what the specialist they are referred to does.  e.g. What is a Rheumatologist?  What is a Radiation Oncologist?

3.  The patient has the ability to add any additional questions they may have for the specialist to the initial referral letter sent by their physician.

4.  An FAQ education section built into the referral portal offers multiple benefits.  First it prompts the patient to common questions people may have when they see that type of specialist. Second, it provides immediate answers. Third, if the answers are unsatisfactory to the patient, it is easy for the patient to add these questions to their section on the referral letter.

5.  After the appointment the patient receives a copy of the specialist's letter. (See the OpenNotes study to see what happens when patients read their notes.)

Has anyone has seen an EHR with this feature? Any ways improve the idea? Let me know, gschmidt@medmb.ca