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.