title: Follow-up actions on electronic referral communication in a multispecialty outpatient setting.
abstract: OBJECTIVE
  Electronic health records (EHR) enable transmission and tracking of referrals between primary-care practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronic referral communication in a large multispecialty VA facility.
  
  
  METHODS
  We retrieved outpatient referrals to five subspecialties between October 2006 and December 2007, and queried the EHR to determine their status: completed, discontinued (returned to PCP), or unresolved (no action taken by subspecialist). All unresolved referrals, and random samples of discontinued and completed referrals were reviewed to determine whether subspecialists took follow-up actions (i.e., schedule appointments anytime in the future) within 30 days of referral-receipt. For referrals without timely follow-up, we determined whether inaction was supported by any predetermined justifiable reasons or associated with certain referral characteristics. We also reviewed if PCPs took the required action on returned information.
  
  
  RESULTS
  Of 61,931 referrals, 22,535 were discontinued (36.4%), and 474 were unresolved (0.8%). We selected 412 discontinued referrals randomly for review. Of these, 52% lacked follow-up actions within 30 days. Appropriate justifications for inaction were documented in 69.8% (150/215) of those without action and included lack of prerequisite testing by the PCP and subspecialist opinion that no intervention was required despite referral. We estimated that at 30 days, 6.3% of all referrals were associated with an unexplained lack of follow-up actions by subspecialists. Conversely, 7.4% of discontinued referrals returned to PCPs were associated with an unexplained lack of follow-up.
  
  
  CONCLUSIONS
  Although the EHR facilitates transmission of valuable information at the PCP-subspecialist interface, unexplained communication breakdowns in the referral process persist in a subset of cases.
authors.affiliation: Houston VA HSR&D Center of Excellence and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. hardeeps@bcm.tmc.edu
authors.forename: Hardeep
authors.initials: H
authors.lastname: Singh
authors.forename: Adol
authors.initials: A
authors.lastname: Esquivel
authors.forename: Dean F
authors.initials: DF
authors.lastname: Sittig
authors.forename: Daniel
authors.initials: D
authors.lastname: Murphy
authors.forename: Himabindu
authors.initials: H
authors.lastname: Kadiyala
authors.forename: Rachel
authors.initials: R
authors.lastname: Schiesser
authors.forename: Donna
authors.initials: D
authors.lastname: Espadas
authors.forename: Laura A
authors.initials: LA
authors.lastname: Petersen
mesh_terms: D000553:Ambulatory Care / Q000379:methods / Q000592:standards*; D003266:Continuity of Patient Care / Q000592:standards*; D057286:Electronic Health Records / Q000592:standards*; D006801:Humans; D033183:Interdisciplinary Communication; D016347:Medical Records Systems, Computerized / Q000592:standards; D008511:Medicine / Q000592:standards; D058007:Physicians, Primary Care / Q000592:standards; D012017:Referral and Consultation / Q000592:standards*; D012189:Retrospective Studies