Study: Data-Sharing Limitations Hamper Referral Loop Closure

Physicians interviewed in a recent study said that among the most significant barriers to closing referral loops is the inability of EHRs to share information across healthcare systems and clinicians’ continued reliance on fax machines or patient conveyance of paperwork.

A referral loop is when patients are referred and seen by specialists and then return to their primary care providers. A study led by Regenstrief Institute Research Scientist April Savoy, Ph.D., and published in ScienceDirect noted that between a third and half of referral loops are not closed, potentially resulting in patients not getting the care they need, which can compromise safety and health outcomes.

The paper explores primary care physicians’ and specialists’ perceptions of the causes and experiences with referral loop breakdowns. Both primary care and specialist physicians reported technological and organizational barriers to the successful completion of the referral loop.

The researchers noted that a health information exchange has potential to play a role in this use case, for instance, by presenting the consultant’s treatment plan to the referrer. “However, low adoption rates, poor usability, and implementation issues with HIE technologies have limited their use and effectiveness.”

Six referring primary care physicians and 12 consultants from two healthcare systems and four medical specialties participated in the study. Physicians perceived three main barriers in external referrals: receipt of excessive and unnecessary faxed documents, missing or delayed documentation, and organizational policies regarding information privacy interfering with closing the loop. Compared to internal referrals, physicians reported increased staff burden, patient frustration, and delays in diagnosis with external referrals, the researchers found.

Consultants reported the ability to provide the same level of care to patients with internal or external referrals. However, consultants described communication breakdowns that prohibited confirmation of follow-up plan retrieval, initiation, or effectiveness.

“If there's a breakdown, whether due to communication, inaccessible information, payment or other factors, patient care may be compromised. When referral loops aren’t closed, there can be an increase in patient safety risk, malpractice lawsuits, clinician burden and other adverse events,” said Savoy, a human factors engineer and health services researcher, in a statement. “In addition to technological barriers, we learned more in this study about organizational barriers for referral loops involving inconsistent information-sharing policies across healthcare systems."