4 Flaws Crippling Modern Referral Workflows

Posted by Christian Kratsas on 12/8/16 6:45 PM


An alarming number of primary care practices don’t have the staff required to proactively manage referrals. Medical assistant teams lack the capacity required to manage chronic care and quality programs, meet payor requirements, and hunt consult reports from specialists. As a result, these practices manually track referrals only when they are required to for regulatory requirements or internal referral initiatives.

The primary care practices that are proactively managing referrals are doing so with an overwhelming amount of expensive and manual workflow. Care coordinators are adding hundreds of hours to their workflow each month to ensure that patients are completing their appointment and that specialists are returning the clinical information needed for appropriate follow up.

In contrast, primary care practices that automate their referral workflow electronically are recovering up to 70% of their staff’s time [1] spent manually managing referrals.

Improved referral processes help practices meet value-based initiatives and devote time to programs that drive revenue—like preventative and chronic care management.So what happens when closing the referral loop is unattainable?

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Poor patient handoffs

The breakdown begins when the primary care doctor hands his patient a paper referral. Practices reactively managing referrals simply enter the referral order into the electronic health record and leave the scheduling up to the patient.

According to the Journal of General Internal Medicine, only 32% of specialists will receive clinical information from the PCP prior to seeing the referred patient.

In addition, care agreements that hold specialty partners accountable for scheduling the patient for their referred appointment don’t exist. The lack of shared accountability between primary and specialty care causes just 50% of referrals to result in a completed appointment [2].

Can’t track patients across the continuum of care

Currently, primary care has limited visibility into the patient journey once the referral is made. Referral coordinators are struggling to answer simple questions like:

  • Did they actually schedule an appointment?
  • When is their appointment?

One referral coordinator at a primary care physician office in Pittsburgh, PA shared a story about a common problem that happens when a primary care office has no referral tracking. A patient was referred by the PCP office to an orthopedic specialist 2 months earlier. The patient called back to try to make another PCP appointment. “You’re trying to tell them, well did you ever call the specialist? And they say ‘no,’ and they want to come back to the PCP office. And that creates a problem because the doctor already said well you need to see the specialist, this is out of my field.”

Without a dedicated referral management platform, large primary care practices that want to close the loop on referrals have to staff full-time employees to:

  • Manually run reports from the EHR to see what referral orders are currently open.
  • Call through the list of identified open orders to determine if the patient scheduled an appointment.
  • If an appointment was made, take note of the date and create a reminder to follow-up.
  • If an appointment was not made, provide education on the importance of scheduling the appointment.
  • In special cases, reach out to the specialist to get the patient scheduled.
  • Follow-up with the specialist to retrieve a consult report once the appointment is completed.

As a result, time-consuming referral processes cause practices to close the loop on only a small percentage of referrals.

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Wasted time on phone and fax

When clinical documentation isn’t handy, specialist front-office staff wastes time on the phone chasing down the patient’s records. In most cases, the mad scramble to uncover a transition-of-care document or test results occurs while the patient is already in the waiting room. Inefficient lines of communication are not only wasting the time of administrative staff, but also the patient.


Even after a referred specialty appointment is completed, most specialists fail to follow up with the referring primary care office.

  • A study in the Milbank Quarterly found that only 20% of consult reports will proactively make it to the referring PCP in time for the patient’s follow up appointment.
  • The Archives of Internal Medicine argues that 40% of the time specialists don’t proactively send a consult report, adding yet another manual step to the referral workflow.
  • In a similar survey by the Journal of Internal Medicine, another 40% of time specialists don’t send a consult in time for the patient’s follow up meeting with their primary care doctor.

Once a consult report is returned, care coordinators spend extra time integrating it into their EHR. Premier Inc even claims that “they [EHRs] weren’t developed to incorporate data from specialists.” Practices without an electronic fax system go as far as scanning the consult report and uploading it into the patient’s chart in their EHR.

Long lead times when scheduling appointment

Given the lack of referral tracking, primary care has no visibility into the time it takes their specialty partners to see their referred patient. Without data such as average time to appointment, primary care leadership can’t collaborate with certain specialties to increase their availability for referrals.

The lack of timely availability is deterring patients from scheduling important appointments needed to prevent serious conditions.

As an answer to the current state of manual and inefficient referral management, the Milbank Quarterly states that “deficiencies in the referral process and care continuity have many adverse consequences.” Broken referral processes lead to suboptimal primary and specialty care and suboptimal continuity of care, which have been shown to lead to missed or delayed cancer diagnoses, poor patient satisfaction, and increased risk of malpractice suits.

Get deeper insights to learn how your practice can build a better care coordination workflow. Click below to download our guide and improve your referral management with automation.



[1] Treatspace time-study

[2] Archives of Internal Medicine http://www.ncbi.nlm.nih.gov/pubmed/22271124

[3] Annals of Internal Medicine http://www.ncbi.nlm.nih.gov/pubmed/17015866


Topics: Coordinated Care