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Follow-up Actions on Electronic Referral Communication in a Multispecialty Outpatient Setting

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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.


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.


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.


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.

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Funding Source

The study was supported by an NIH K23 career development award (K23CA125585) to Dr. Singh, the VA National Center of Patient Safety, and in part by the Houston VA HSR&D Center of Excellence (HFP90-020).

These sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs.


All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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None disclosed.

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Correspondence to Hardeep Singh MD, MPH.

Additional information

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Support: The study was supported by an NIH K23 career development award (K23CA125585) to Dr. Singh, the VA National Center of Patient Safety, and in part by the Houston VA HSR&D Center of Excellence (HFP90-020).

Prior Presentations: Part of the results presented in this manuscript were presented as an abstract at the Annual Meeting of the Society of General Internal Medicine on May 15, 2009.

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Singh, H., Esquivel, A., Sittig, D.F. et al. Follow-up Actions on Electronic Referral Communication in a Multispecialty Outpatient Setting. J GEN INTERN MED 26, 64–69 (2011).

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