When referring a patient to a specialist, the pediatrician is requesting advice or direct patient care usually because the patient’s condition is outside the pediatrician’s expertise. The consultation process is a valuable tool for a primary care provider and medical home.
There is no guarantee, however, that the parent or guardian will comply with the recommendations. If the patient has an untoward outcome because consultation with an expert did not occur with the proper timing, the referring doctor could face medical liability consequences.
A general pediatrician examines a 1-month-old patient, becomes concerned about a dull red reflex and refers the patient to an ophthalmologist. At the 2-month checkup, leukocoria is evident. The pediatrician learns that the parent, not understanding the urgency, has not yet seen the consultant. An urgent consult is completed within two days, and a retinoblastoma is diagnosed.
A general pediatrician examines an 8-year-old with persistent asthma, becomes concerned about a possible dietary allergy and refers the patient to an allergist. The parent plans to schedule the appointment over a school vacation. Before that happens, the patient is hospitalized with anaphylactic shock.
Explaining to the parent the reason for and importance of the referral, tracking whether the patient actually saw the specialist, and communicating with the specialist can help safeguard against liability risk.
Failure/delay in referral or consultation is one of the top 10 medical factors in pediatric malpractice claims involving diagnostic errors. Nearly half of claims with referral problems end in malpractice payouts. Usually, a patient is referred by a generalist to a specialist. Sometimes, however, a specialist may refer a patient to a physician of a different specialty.
Evidence supports that co-management of care between specialists and primary care providers results in better health outcomes for patients with chronic diseases.
The referral process begins with the decision to refer and choosing the correct specialist. The decision to refer varies widely among primary care providers and is influenced by many factors such as the nature of the presenting problem, the patient’s expectations, the provider’s experience with the condition and practice style, and the practice environment. Choice of a consultant should be based on the specialist’s expertise and competence, and may be limited by the patient’s health insurance plan.
Even though health care providers value communication, patient surveys indicate that problems with information transfer occur frequently. According to studies of specialty referrals, there was no communication between providers either before or after the consult was performed in about half of referrals.
Timeliness and thoroughness of information transfer is extremely important. Up to 70% of specialists have rated the background information they received as fair to poor. Inadequate information transfer can result in the specialist not knowing the reason for or urgency of the consultation, which can delay its completion.
Approximately 50% of referring physicians do not know whether their patients have actually seen the specialist to whom they were referred. This gap in the referral process can be associated with delay in consultation completion, inefficient care, worse patient satisfaction and liability risk.
While it may be somewhat labor intensive, referral tracking is an important task for the referring provider because it is the only way to know with certainty that the patient saw the specialist and when. Utilizing the same electronic health record (EHR), as occurs in multispecialty groups, allows for ease of information transfer and referral tracking between providers. Occasionally, however, the parent may choose to see a different provider than the one recommended, creating additional obstacles for these processes.
Obstacles to patient compliance
Communication lapses among physicians, their patients and other health care providers frequently are the focus of malpractice claims. Common claims for noncompliance with referrals include that the physician did not stress the importance, fully explain the reason, clearly indicate the potential bad outcome or explicitly state that a referral is necessary as opposed to optional.
Risk management strategies for referring physicians
- Clearly explain to the parent the reason for the referral and whether you are concerned about something potentially serious; document this conversation in the medical record.
- Communicate to the specialist the reasons for the consultation and indicate the degree of urgency.
- If the potential health concern is time sensitive so that failure or even delay in obtaining the specialist’s assessment likely will cause injury to the child, then a phone call directly to the consultant is appropriate and can facilitate scheduling an appointment. In this case, it is particularly prudent for the pediatrician to track timely compliance.
- Consider a system for tracking referrals (e.g., a suspense file or EHR follow-up list for all pending referrals), which includes making reminder phone calls, scheduling follow-up appointments or calling parents to discuss consultant recommendations. It is important to include a backup plan for intervening if a referral is not completed in the expected period of time.
- Document the follow-up plan, further discussions with parent and/or consultant, phone calls and review of consultant’s letters (e.g., written initials and the date or e-signature/attestation in the EHR, etc.).
Dr. Altman is a member of the AAP Committee on Medical Liability and Risk Management.