Journal of General Internal Medicine

, Volume 33, Issue 5, pp 715–721 | Cite as

Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialists in a Large Health System

  • Malhar P. PatelEmail author
  • Priscille Schettini
  • Colin P. O’Leary
  • Hayden B. Bosworth
  • John B. Anderson
  • Kevin P. Shah
Original Research



Ideally, a referral from a primary care physician (PCP) to a specialist results in a completed specialty appointment with results available to the PCP. This is defined as “closing the referral loop.” As health systems grow more complex, regulatory bodies increase vigilance, and reimbursement shifts towards value, closing the referral loop becomes a patient safety, regulatory, and financial imperative.


To assess the ability of a large health system to close the referral loop, we used electronic medical record (EMR)-generated data to analyze referrals from a large primary care network to 20 high-volume specialties between July 1, 2015 and June 30, 2016.

Main Measures

The primary metric was documented specialist appointment completion rate. Explanatory analyses included documented appointment scheduling rate, individual clinic differences, appointment wait times, and geographic distance to appointments.

Key Results

Of the 103,737 analyzed referral scheduling attempts, only 36,072 (34.8%) resulted in documented complete appointments. Low documented appointment scheduling rates (38.9% of scheduling attempts lacked appointment dates), individual clinic differences in closing the referral loop, and significant differences in wait times and distances to specialists between complete and incomplete appointments drove this gap. Other notable findings include high variation in wait times among specialties and correlation between high wait times and low documented appointment completion rates.


The rate of closing the referral loop in this health system is low. Low appointment scheduling rates, individual clinic differences, and patient access issues of wait times and geographic proximity explain much of the gap. This problem is likely common among large health systems with complex provider networks and referral scheduling. Strategies that improve scheduling, decrease variation among clinics, and improve patient access will likely improve rates of closing the referral loop. More research is necessary to determine the impact of these changes and other potential driving factors.


patient safety access to care managed care population health primary care redesign 



The authors would like to acknowledge Jonathan Woodall, Duke Institute for Health Innovation, and Duke Primary Care. Results of this work were presented at Society of General Internal Medicine meeting (April 2017), American College of Physicians meeting (April 2017), the North Carolina ACP meeting (February 2017), and Duke Patient Safety Conference (March 2017).

Compliance with Ethical Standards

Conflict of Interest

Dr. Bosworth receives research funds through Duke University from NIH, VA, Pharma foundation, Johnson & Johnson, Improved Patient Outcomes, Takeda, and Sanofi. He has received honorarium from Sanofi, Otsuka pharmaceuticals, Genentech, and has been a member of Boehringer Ingelheim Speaking bureau. Other authors report no conflicts of interest.


  1. 1.
    Additional Information Regarding EH Clinical Quality Measures. In: Services CfMM, ed. Baltimore, MD: United States Federal Government; 2014.Google Scholar
  2. 2.
    Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89(1):39–68.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15(9):626–631.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Forrest CB, Glade GB, Baker AE, Bocian A, von Schrader S, Starfield B. Coordination of specialty referrals and physician satisfaction with referral care. Arch Pediatr Adolesc Med. 2000;154(5):499–506.CrossRefPubMedGoogle Scholar
  5. 5.
    Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med. 2005;142(8):700–708.CrossRefPubMedGoogle Scholar
  6. 6.
    Weiner M, Perkins AJ, Callahan CM. Errors in completion of referrals among older urban adults in ambulatory care. Journal of evaluation in clinical practice. 2010;16(1):76–81.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
  8. 8.
    Services CfMM. Quality measures. 2017. Accessed January 26, 2018.
  9. 9.
    2009. National patient safety goals. In: Organizations TJCoAoH, ed. Joint commission resources. 2008.Google Scholar
  10. 10.
    2017. National Patient Safety Foundation and CRICO to Collaborate on Referral Management Best Practices [press release]. PRWeb, January 26, 2018.Google Scholar
  11. 11.
    Fahey P, Cruz-Huffmaster D, Blincoe T, Welter C, Welker MJ. Analysis of downstream revenue to an academic medical center from a primary care network. Academic medicine : journal of the Association of American Medical Colleges. 2006;81(8):702–707.CrossRefGoogle Scholar
  12. 12.
    Kinchen KS, Cooper LA, Levine D, Wang NY, Powe NR. Referral of patients to specialists: factors affecting choice of specialist by primary care physicians. Annals of Family Medicine. 2004;2(3):245–252.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Cuellar AE, Gertler PJ. How the expansion of hospital systems has affected consumers. Health affairs (Project Hope). 2005;24(1):213–219.CrossRefGoogle Scholar
  14. 14.
    Cuellar AE, Gertler PJ. Trends in hospital consolidation: the formation of local systems. Health affairs (Project Hope). 2003;22(6):77–87.CrossRefGoogle Scholar
  15. 15.
    Widdifield J, Bernatsky S, Thorne JC, et al. Wait times to rheumatology care for patients with rheumatic diseases: a data linkage study of primary care electronic medical records and administrative data. CMAJ open. 2016;4(2):E205–212.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Jaakkimainen L, Glazier R, Barnsley J, Salkeld E, Lu H, Tu K. Waiting to see the specialist: patient and provider characteristics of wait times from primary to specialty care. BMC family practice. 2014;15:16.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163–170.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Hacker KA, Weintraub TA, Fried LE, Ashba J. Role of school-based health centers in referral completion. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 1997;21(5):328–334.CrossRefGoogle Scholar
  19. 19.
    Byrd JC, Moskowitz MA. Outpatient consultation: interaction between the general internist and the specialist. J Gen Intern Med. 1987;2(2):93–98.CrossRefPubMedGoogle Scholar
  20. 20.
    Bourguet C, Gilchrist V, McCord G. The consultation and referral process. A report from NEON. Northeastern Ohio Network Research Group. The Journal of family practice. 1998;46(1):47–53.PubMedGoogle Scholar
  21. 21.
    Rowe J. 3 benefits of eReferral systems. 2013. Accessed January 26, 2018.
  22. 22.
    Dydra L. Make patient referrals count: how a new technology platform impacts patient care & provider economics. 2014. Accessed January 26, 2018.
  23. 23.
    Baum S. A Q&A with AristaMD CEO: The shifting landscape of the specialist referral software sector. 2016. Accessed January 26, 2018.
  24. 24.
    Deckard GJ, Borkowski N, Diaz D, Sanchez C, Boisette SA. Improving timeliness and efficiency in the referral process for safety net providers: application of the Lean Six Sigma methodology. J Ambul Care Manage. 2010;33(2):124–130.CrossRefPubMedGoogle Scholar
  25. 25.
    Esquivel A, Sittig DF, Murphy DR, Singh H. Improving the effectiveness of electronic health record-based referral processes. BMC Med Inform Decis Mak. 2012;12:107.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Kaandorp GC, Koole G. Optimal outpatient appointment scheduling. Health care management science. 2007;10(3):217–229.CrossRefPubMedGoogle Scholar
  27. 27.
    Kwong T. Patient access: improving wait times in a specialty clinic. The health care manager. 2016;35(1):72–79.CrossRefPubMedGoogle Scholar
  28. 28.
    O'Neill S, Calderon S, Casella J, Wood E, Carvelli-Sheehan J, Zeidel ML. Improving outpatient access and patient experiences in academic ambulatory care. Academic medicine : journal of the Association of American Medical Colleges. 2012;87(2):194–199.CrossRefGoogle Scholar
  29. 29.
    Snow BW, Cartwright PC, Everitt S, Ekins M, Maudsley W, Aloi S. A method to improve patient access in urological practice. The Journal of urology. 2009;182(2):663–667.CrossRefPubMedGoogle Scholar
  30. 30.
    Waldron MA, Scott K. Improved scheduling operations in diagnostic imaging. Radiology management. 2013;35(1):30–35; quiz 36-37.PubMedGoogle Scholar
  31. 31.
    Weiner M, El Hoyek G, Wang L, et al. A web-based generalist-specialist system to improve scheduling of outpatient specialty consultations in an academic center. J Gen Intern Med. 2009;24(6):710–715.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Davis A, Gilchrist V, Grumbach K, James P, Kallenberg R, Shipman SA. Advancing the primary/specialty care interface through eConsults and enhanced referrals. Ann Fam Med. 2015;13(4):387–388.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Chen AH, Murphy EJ, Yee HFJ. eReferral—a new model for integrated care. New England Journal of Medicine. 2013;368(26):2450–2453.CrossRefPubMedGoogle Scholar
  34. 34.
    Gleason N, Prasad PA, Ackerman S, et al. Adoption and impact of an eConsult system in a fee-for-service setting. Amsterdam, Netherlands: Healthcare; 2016.Google Scholar
  35. 35.
    Keely E, Liddy C, Afkham A. Utilization, benefits, and impact of an e-consultation service across diverse specialties and primary care providers. Telemed J E Health. 2013;19(10):733–738.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Kim Y, Chen AH, Keith E, Yee HF Jr, Kushel MB. Not perfect, but better: primary care providers’ experiences with electronic referrals in a safety net health system. J Gen Intern Med. 2009;24(5):614–619.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Kim-Hwang JE, Chen AH, Bell DS, Guzman D, Yee HF Jr, Kushel MB. Evaluating electronic referrals for specialty care at a public hospital. J Gen Intern Med. 2010;25(10):1123–1128.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Malhar P. Patel
    • 1
    Email author
  • Priscille Schettini
    • 1
  • Colin P. O’Leary
    • 1
  • Hayden B. Bosworth
    • 1
    • 2
    • 3
  • John B. Anderson
    • 4
  • Kevin P. Shah
    • 4
  1. 1.Duke University School of Medicine, 8 Duke University Medical CenterDurhamUSA
  2. 2.Durham Veterans Affairs Medical CenterDurhamUSA
  3. 3.Department of Population Health SciencesDuke University Medical CenterDurhamUSA
  4. 4.Duke Primary CareDuke University Health SystemDurhamUSA

Personalised recommendations