A generic referral template is a better idea than specialty-specific templates

A lot of people have been thinking about how to improve the GP-specialist consultation process.  It's going on at the national level.  It's going on at the local level.  And, as part of the Saskatchewan Surgical Initiative, there's interest provincially.

Recently, I had a conversation with someone about what would be the best first step on a provincial level.  Should we develop a general referral template that the referring doc could use for any specialty, or is it better to make specific referral forms that address the information needs of each specialty?

My first thought was that specialty-specific forms would be best.  They would give more useful information to allow the receiving specialist to anticipate the patient's need for special testing or procedures.  They would also allow inclusion of a management algorithm (suggested by each specialty group) to help the referring physician complete the initial steps in diagnosis and therapy.

I still think a specialty-specific form would be ideal, but on further consideration, it's not the best first step.

With respect and gratitude to all my colleagues who make the effort to write a complete referral letter, I receive many inadequate referral letters.  At our office, our staff spends a lot of time calling back to referring docs' clinics to ask for lab and xray results, and details of the patient's condition.  The really annoying thing is that the results we need are actually available, but the referring doc didn't think to send them along.  This slows down the assessment process as I can't give a final opinion without these results.   Also, we may schedule more testing, only to find out that it has already been completed.  

From conversations with specialist colleagues locally and nationally, I know that this is a universal problem.  As such, I think that all specialists (and patients!) could benefit from a generic referral form that prompts referring docs to give the basic information needed in a referral letter:

Reason for referral/clinical question to be answered

History of present problem including treatments tried and the outcome

Past medical history

Medications

Allergies

Test results (lab and xray)

Other information could include urgency of the consultation, any special conditions of note (physical or mental limitations).

Perhaps a specialty-specific form would be developed later, although it would take exponentially more work to create.  Getting each specialty group to agree about the minutia on such a form would take a long time.   Also, in the absence of an electronic storage system, GPs would likely find it cumbersome to file myriad specialty-specific forms.  I'm not sure that the marginal utility of developing a specific form would warrant the effort.

However, given the above-griped-about scarcity of information on many referral letters, all specialists would get at least some benefit out of a global, generic referral template.  

I suggest starting with a basic form, including the information noted above.  The form should be clearly marked "DRAFT #X.  EXPIRY DATE: XXX".  This would prevent having multiple (confusing) iterations of the form drifting around a doctor's office.  

There would be a mechanism for feedback from both the GP and specialist.  Perhaps it would be tear-off section, or a second page that could be faxed back to the developers.

Start small - perhaps with two or three GPs.  Getting feedback from them would be simple, as they are small group, chosen by the developers.  Blank forms could be sent out to specialists for comment, or the GPs could complete some forms with simulated patients so as to solicit reviews from specific specialists.

Run short PDSA cycles - two weeks at most.  Collect feedback on which content is most useful, and also what design makes the form easy to complete (for the GP) and read (for the specialist).  Make it clear that this is not meant to be an all-encompassing form.  The project will get bogged down if everyone gets to add their "pet peeve" to the mix.  The developers need to be ruthless about this.  

After each cycle, expand the GP user group.  I think we would have a pretty useful (not perfect!) form within 3 months.  

I wouldn't blame any family docs who might be reading this for getting cheesed off at my impertinence and stopping several paragraphs back.  But, if you're still with me, let me say that I think this should be a two-way street.  Half of the consultation process is the information contained in the referral letter.  The other half is the information the specialist provides in a consultation report.  Specialists are not squeaky clean here.  GPs point out they often wait a long time to receive reports.  Their clinical question may not be answered.  The consultation letter may be difficult to read as it may be several pages long, with any requests for further testing or recommendations for management buried inside the text.  There may be no indication as to whether the GP is expected to provide ongoing care, or whether the specialist will do it. 

Specialists can do better too. 

There should be a similar template to help specialists provide good quality consultation reports that will help the GP manage the patient's care.  We could run parallel PDSA's to address this side of the equation.

We could have a generic referral form and consultation report template ready within 6 months.  The biggest barrier would be too much fine-tuning.

Perfect is the enemy of good.

Simplicity is its own reward

Sarah posted an interesting comment about the GP-specialist referral process:

I often wonder if simplification from the patient view can contribute to simplification from the doc's point of view.

Hmmm. Ideally, yes, but I have some reservations.

An elegantly designed system completes tasks reliably, consistently and with minimal waste. The simplicity of such a system would be evident to all users.

However, if the system is poorly designed, then not all users will “see” the simplicity. One user group may end up doing more work in order to use the system, or may suffer confusion, extra expense, and/or wasted time. Often, as healthcare tends to be provider-centred, it’s the patient who is saddled with the extra work and waste.

However, there are instances where providers will take on the extra work for the benefit of patients. This makes the process simpler for patients, but more complicated for providers. I would call this “faux-simplicity”. An example of this would be the Navigator role in healthcare.

A Navigator – often a nurse - guides patients through the complex journey of diagnosis and treatment. For example, a man who is suspected of having prostate cancer may have multiple contacts with the healthcare system including prostate biopsy, CT and bone scans, one (or more) specialty consultations, radiation treatment and surgery. It’s a huge help for the man to have the Navigator coordinate testing and travel for the man.

But, the presence of a Navigator doesn’t make the system simpler.

The patient may perceive less work and worry, but the system remains complex, and the Navigator and other providers still struggle with its waste and inefficiency. (Perhaps the perceived need for a Navigator is an admission that the system is badly broken!)

Does it matter that providers have to do more work, as long as patients are freed from the burden? Yes, it does matter. More time and resources spent wrestling with an inefficient, poorly coordinated system means less time and resources spent giving value to patients.

Ideally, a Navigator position is created as part of a broader, patient and family-centred system redesign. The Navigator would help with that improvement process and, once the system is truly simple and efficient, the Navigator should be out of a job!

An example of patient-centred simplicity that would also be simple for providers is a multidisciplinary cancer clinic. If a man were diagnosed with prostate cancer, he would visit the clinic – perhaps for several hours - where all the necessary testing and consultation would be done in one session. This would involve using Advanced Access principles to ensure same-day access to CT and bone scans. The man could see a urologist, oncologist, nurse specialist, dietician and social worker. The providers’ work is simpler because they can confer at once (with the man and his family, of course) and decide on the preferred treatment.

With current disjointed systems, each provider sees the man independently and then corresponds with other providers. This wastes the man’s time, delays treatment and is prone to miscommunication. Doctors waste more effort when they revisit the man’s chart repeatedly as each new report comes in from other consultants.

So, Sarah, I agree that simpler for the patient can mean simpler for the doctor, but it’s not necessarily so. Watch out for faux-simplicity: kludging another layer of service onto a dysfunctional process, rather than tearing it down and redesigning it so that it is truly patient-centred.

And simpler for everyone.

Listening to my FP colleagues - Part 2

Last month, I heard from family practitioners (FP) from across Canada about what they thought was lacking in the FP-specialist referral process. Last week, I had another opportunity to learn what’s on the minds of my FP colleagues.

As part of the Sask Surgical Initiative (SkSI), care pathways are being created for conditions like back pain or hip problems. I’m participating in developing a prostate cancer pathway. Our working group has mapped out the current state in the province, that is what path men currently follow when diagnosed and treated for prostate cancer. Now we want to explore changes that could make the journey quicker, smoother and more effective, or as SkSI puts it “Sooner, safer, smarter”.

An important part of the working group’s next step is broad representation of interested parties, and FPs play a central role in the process. They do the initial testing that raises suspicion that a man may have prostate cancer. They make the referral to a specialist. They provide education, support and ongoing care as a man has treatment. They are often responsible for long-term follow-up after the man’s treatment.

We need the perspective of an FP on our working group, so I met with the executive council of Saskatchewan’s section of family practice to ask for their help in recruiting one of their members. While supportive of the prostate cancer pathway, they made a couple of pointed comments.

Make our work simpler. Many well-intentioned groups are developing guidelines, checklists, templates and standardized forms to help manage specific conditions. While each of these efforts makes sense in the context of that condition, when FPs are bombarded by dozens of documents, it’s bewildering. Without consistent design, the learning curve starts anew when completing each form.

Perhaps the end users of these documents (in this case, FPs) should insist that any new forms adhere to a common template. If a template is too restrictive, then a set of design principles such as font size, page layout and completion instructions could be used. As one of the FPs pointed out, “Poorly designed forms may only take me an extra 30 seconds to fill out, but that adds up over the course of a day.”

Ultimately, an electronic medical record would solve these problems by “imposing” a style template and virtually filing all documents in one location.

Compensate us appropriately. There were strong feelings about this one. Because of their central role in patient care, FPs are asked to participate on a multitude of committees, boards, and working groups. This work often happens outside of regular work hours and so interferes with family life. When the meetings occur during regular work hours, fee-for-service FPs are often asked to sacrifice practice income.

One of the FPs pointed out that when committees didn’t pay him for his attendance, they undervalued his time. He had been asked to sit for hours through deliberations that didn’t involve him, just so he could participate in discussion of a single relevant issue. He felt that if he were being reimbursed at the same hourly rate he could earn working in his office, the committee would be more careful to schedule the meetings so he was present only when truly necessary.

Others pointed out that most administrators sitting on health-related committees are salaried employees, and so don’t pay any financial penalty for the time they spend at meetings.

I’ve been relatively insulated from the financial burden imposed by participating in administrative work. The pooled revenue-sharing nature of our urology practice means that our group can support one or more individuals taking on non-clinical work that we see as important for advancing patient care. However, if I were a solo, fee-for-service practitioner, taking a day away from my practice could end up costing over $1000 in lost income, with overhead expenses continuing to mount in my absence.

The executive committee indicated they would support our effort to recruit FP representatives for our prostate cancer pathway initiative if our recruiting message included the offer of a stipend. To be fair, I think that stipend should be offered to all non-salaried participants, including specialists and community representatives.

That puts the ball squarely back into the government/SkSI’s court. What other consultants provide their expertise for free?

P.S. I received a stipend for attending the CMA meeting last month...

Improving the FP-specialist referral process

Last week, I attended a joint conference of the Canadian Medical Association’s specialty and family practice (FP) representatives. This was the second year of the joint meeting and the theme was the same: How to improve the referral process between specialists and FPs.

The main task was to identify problems with the current system. There was no shortage of suggestions/complaints.

From the specialists:

Inadequate information in the referral letter (e.g. no medical history or list of medications)

No clear clinical question to be answered by the specialist

Tests results not included in the referral letter

Illegible writing

Inappropriate referral (to the wrong specialist)

No indication as the urgency of the problem

Referral initiated too late in the course of the patient’s illness

Treatment recommendations or requests for further testing not carried out (“I don’t think anyone read the consultation letter I sent back.”)

FP not willing to manage chronic conditions, even with specific recommendations in my consultation letter

And just so specialists don’t get too smug, the FPs shot back with:

Don’t know if the specialist has received my referral letter

Not clear if the specialist will contact the patient with an appointment, or whether I should do it

Don’t know how long the wait times are

Don’t know what tests the specialist wants done ahead of time

Delay in receiving consultation report

Clinical question not answered in consultation report

Not clear who is responsible for providing ongoing care for chronic conditions

Don’t know what each specialist’s sub-specialty interests are

Some comments that came up during general discussion were interesting:

Calling the process a “referral” implies the necessity of a face-to-face visit between specialist and patient. We should consider the process a “consultation” which suggests an exchange of information between FP and specialist. This could be accomplished by phone, email or hallway conversation.

Funding mechanisms (such as fee-for-visit) limit solutions. Several practitioners who worked under alternate funding programs talked about using telehealth, phone calls and email to great advantage. This is (financially) unattractive for fee-for-visit specialists, unless their jurisdiction has fee codes covering these options.

Some of the solutions aimed to improve the content and quality of the referral letter using standardized templates and checklists. Our clinic’s microhematuria algorithm is an example of this with its request for specific testing to be completed before the urologic consultation.

I’m most encouraged by efforts that go beyond just the fine-tuning of the current process. Some people are trying to make referrals more appropriate, or even render them unnecessary.

For example, the Saskatchewan Surgical Initiative’s back pain pathway trains FPs on how to better distinguish surgical and nonsurgical candidates. Patients who are unlikely to benefit from surgery can be immediately directed to the appropriate treatment (physiotherapy, exercise) rather than languishing on a surgeon’s wait list, only to be eventually given the same advice.

A clinic in Northwest Territories is looking at common reasons for specialist referral, and then targeting FP professional development around those topics. Increased FP expertise and confidence for treating common “specialty” conditions will reduce specialist referral rates and allow patients more prompt treatment.

The patient referral process is the key interface between FPs and specialists, and as with many of the “hand-offs” in healthcare, it’s fraught with problems. After attending this conference, the two biggest problems I see are these:

There’s no feedback system to educate either FPs or specialists as to the quality of their contribution to the referral process. In the current system, a FP can send me a referral letter with inadequate clinical information, yet will get a complete consultation report in return. From his/her point of view, the referral letter got exactly the intended result, so why should they change their behaviour? As one of my partners is fond of saying, “What you permit, you promote”! Of course, it works both ways; if I don’t answer the FPs clinical question or help the patient with their problem, I will only know about it if the patient is referred back to me for further assessment. Neither of us can improve unless we’re shown – in an objective and constructive way – where we need to improve. I know that peer feedback would be a strong incentive for me to provide a better service.

An even deeper problem is lack of patient involvement in improving the referral process. The FP/specialist conference clearly focused on perceived physician needs. As healthcare workers, we often flatter ourselves that we can represent our patients’ interests in these matters. My experience in working with patient representatives on similar groups is that they bring a perspective that we lack. As such, I recognize that I can’t predict what a patient would add to the discussion. But, I’ll take a stab at it anyway:

No clear clinical question? I’ll tell you the question, because I’m the one with the problem.

Not enough medical history on the referral? Let me fill that out for you.

I’m being referred for pain in my knee. You “don’t do knees”? Well, then you better make that crystal clear right away, because I don’t want to wait 9 months to hear it.

I drove 4 hours and stayed in a hotel overnight to have a 10-minute discussion with you. Why couldn’t we do that over the phone? Because you get paid more if I turn up in person!? If I knew that ahead of time, I would have made the phone call, paid you the difference and still come out ahead.

Maybe next year we can get some input from the people who are truly affected by a dysfunctional referral process.

Awkward

The problem with first-year medical students is that they haven’t yet learned which questions not to ask.

Two weeks ago, I had a student spending the afternoon with me at my office. We met a patient and his wife, and talked with them about the results of a CT scan he had done earlier in the day. After the visit, the student asked me "Why did he have to come to your office today?" Her concern was that the man had difficulty walking and had recently moved into a care home an hour away from Saskatoon. It was a significant effort for them to travel, both to get to Saskatoon and then within the city.

My staff is diligent about scheduling CT scans (and other tests) on the same day as an office visit, so I can review the results with the patient. I pointed out to my student that this saves people an extra trip into town.

Then she got really impudent.