Just Tell Me What You Want

This week's Canadian Medical Association Journal was a goldmine.

MD Lounge's topic is "Referrals". Improving our referral system is part of our office's Clinical Practice Redesign effort, but it looks like we're reinventing the wheel! The College of Family Physicians of Canada and The Royal College of Physicians and Surgeons of Canada looked at the referral/consultation process in a 1993 task force report.

In a 2006 review, they suggested 3 features to enhance the process:

• A defined single access point within local referral/consultation systems.

We're the single access point for urology in Saskatoon, and my family physician colleagues say that's very handy for them. Imagine a single website listing all Saskatchewan specialists with their particular area of clinical interest. This would be very valuable in Saskatchewan, where there are regularly new physicians, who aren't familiar with local specialist resources.

A single access point could be leveraged by also providing wait time information (for surgery, in the following examples) for individual specialists (like Alberta), or by region or hospital (like Ontario). Of course, you would make this information public so that patients are better able to choose the specialist they wish to see. This requires a significant investment in infrastructure to measure the wait times and update the website regularly. It doesn't require any change in physician behavior, making it easier to sell to physicians.

The real power of a single access point is the pooled referral process. This has been the single most effective change we've made to reduce our office wait times. As of May 2008, any referrals we receive are automatically assigned to the first available urologist. Patients, and their referring physicians, can choose a particular urologist ("No substitutions") if they wish, but may wait longer for their visit. I like the analogy of an ice-cube tray to explain this system. If you pour water into one compartment of an ice-cube tray, it will automatically spill into the next compartment once the first is full. When we changed from optional pooled referral to "default" pooled referral, it simplified appointment booking for our staff.
A pooled referral system requires a deeply collegial group, and probably some kind of fee sharing agreement. Also, no cherry-picking "easy" cases!

• Templates for referrals and consultation advice
• An agreement among key players (relevant GP/FP and other specialty organizations) on referral/consultation criteria

These two features seem very similar, and reminded me of our hematuria referral initiative. With some conditions, it may be difficult to reach consensus on information required for a referral request. Or, a condition may be so uncommon that it's not worth the effort to develop a standardized referral template. But, hematuria referrals are common and the Canadian Urological Association has already developed guidelines for evaluation.

Last year, we started sending our hematuria referral template to referring physicians. I've been noticing that some referral letters now include the completed template including lab and x-ray results. In "Total Recall," I posted results of a chart review done before the hematuria referral template was distributed. I looked at the adequacy of patient information (past medical history, medications and allergies), as well as test results (lab work and ultrasound).

I reviewed a similar number of charts this week, to see if publicizing the referral template had really made a difference.

The 2007 results are from the previous pre-template review. I looked at 18 charts each time. I didn't bother reporting about patient information this time, as it's very subjective as to what is "adequate" medical history, etc. Also, I only looked at lab/ultrasound reports that were provided in the initial consultation letter, not information that was received as a result of our staff requesting more information from the referring physician's office. The whole point of this referral template was to reduce the number of phone calls my staff has to make, the number of times I need to "handle" a chart (i.e. when new information arrives), and the amount of extra work the referring physician's office has to do. All this is done with the intent of being able to provide our patients with better service: a single specialist visit that includes consultation, any additional testing/examinations, and review of the results.

When I did this review, I also discovered that it's now rare for me to see someone with hematuria in my office. Hematuria referrals are still common, but I just arrange to see them for a combination consultation and cystoscopy (bladder examination) at the hospital. If I can anticipate the need for cystoscopy, I combine all necessary testing into one visit. This further frees up office capacity for other new referrals or review visits.

I've griped previously about the quality and content of referral letters. I wondered why referring docs didn't include all the information I needed to assess patients properly. The above graph shows that the problem is not with the referring docs – it's with the specialists! Once we told them what we actually wanted, referring docs were happy to arrange the testing and get the results to us.

And I thought they could just read my mind!