Communication Breakdown in the Outpatient
Tejal K. Gandhi, MD, MPH, Dean F. Sittig, PhD, Michael Franklin, BS,
Andrew J. Sussman, MD, MBA, David G. Fairchild, MD, MPH, David W. Bates, MD, MSc
cians’ satisfaction with interphysician communication and to
identify the major problems in the current referral process.
To evaluate primary care and specialist physi-
isfaction with the referral process; then patient-specific sur-
veys were e-mailed to this group to obtain real-time referral
Surveys were mailed to providers to determine sat-
Academic tertiary care medical center.
Attending-level primary care physicians (PCPs)
MEASUREMENTS AND MAIN RESULTS:
mail surveys for PCPs was 57% and for specialists was 51%.
In the mail survey, 63% of PCPs and 35% of specialists were
dissatisfied with the current referral process. Respondents
felt that major problems with the current referral system
were lack of timeliness of information and inadequate refer-
ral letter content. Information considered important by re-
cipient groups was often not included in letters that were
sent. The response rate for the referral specific e-mail sur-
veys was 56% for PCPs and 53% for specialists. In this e-mail
survey, 68% of specialists reported that they received no in-
formation from the PCP prior to specific referral visits, and
38% of these said that this information would have been
helpful. In addition, four weeks after specific referral visits,
25% of PCPs had still not received any information from
The response rate for
ferral process. The major issues were physician dissatisfac-
tion, lack of timeliness, and inadequate content of interphy-
sician communication. Information obtained from the general
survey and referral-specific survey was congruent. Efforts to
improve the referral system could improve both physician
satisfaction and quality of patient care.
Substantial problems were present in the re-
J GEN INTERN MED 2000;15:626–631.
ambulatory care; communication; referral and
nized in the managed care era. Physician-to-physician
communication is vital to the success of an outpatient re-
ferral. Optimal communication involves transfer of relevant
clinical information in both directions (from the referring
physician to the specialist and vice versa). Breakdowns in
communication can lead to poor continuity of care, delayed
diagnoses, polypharmacy, increased litigation risk, and
and can therefore decrease the qual-
ity of care.
Difficulties with referrals are commonplace because
of physician time constraints, lack of clarity about rea-
sons for referrals, patient self-referrals, limitations im-
posed by managed care, and unclear follow-up plans.
Several studies have shown that communication between
primary care providers (PCPs) and specialists is subopti-
mal in many ways. In a 1983 study of inpatient consulta-
the requesting physician and the consultant com-
pletely disagreed on both the reason for consultation and
the principal clinical issue in 14% of consultations. In one
outpatient study done in 1980, PCPs only received follow-
up information for 62% of consultations.
spite advances in medicine and communication technol-
ogy, the available data suggest that these figures have not
improved. A 1998 study found that referring physicians
received feedback from consultants in only 55% of cases.
Much of the research on referral communication has
focused on the content of referral letters. In one of those
studies, researchers surveyed general practitioners and
consultants about what a referral letter should include.
A high degree of consensus existed among clinicians
about important content of referral communications. Over
90% of both generalists and consultants agreed that state-
ment of the problem, current medication, and reason for
referral should be in a referral letter. However, several
studies show that letters from general practitioners often
lack critical information, explicit statements of the reason
for consultations, sociopsychological factors, or plans for
For example, one study found that although
referring physicians provided patient background in 98%
of referrals, they made the purpose of the referral explicit
in only 76%.
Developing a better understanding of problems in
communication should be the first step in creating sys-
tems that facilitate better quality referrals. Methods of
communication have significantly changed in the past few
years with the advent of electronic mail (e-mail). However,
it is not clear that better communication is occurring, es-
pecially since physicians are busier than ever. In addi-
he referral process is a critical component of quality
clinical care, and it has become increasingly scruti-
Received from the Division of General Internal Medicine, Brigham
and Women’s Hospital, Harvard Medical School, Boston, Mass
(TKG, AJS, DGF, DWB); and Clinical Systems Research and De-
velopment, Partners Healthcare System, Boston, Mass (DFS, MF).
Dr. Sittig is now with WebMD Inc., Portland, Ore.
Address correspondence and reprint requests to Dr. Bates:
Division of General Medicine, Brigham and Women’s Hospital,
PBB-A3, 75 Francis St., Boston, MA 02115 (e-mail: dbates@
Volume 15, September 2000
tion, little is known about the reasons for inadequate phy-
sician communication and what the significant barriers
are to effective communication from the physicians’ per-
To evaluate our current referral process in order to
improve its quality, we sought to measure physician sat-
isfaction with the current referral process at our institu-
tion; identify the type of communication that is occurring
and evaluate the adequacy of provider communication
both in general and for specific referrals; identify the ma-
jor problems with the current referral system; and identify
potential targets for improvement.
Description of Current Referral Process
This study was performed at Brigham and Women’s
Hospital, an academic tertiary care teaching and referral
center. Our institution has a computerized medical record
including outpatient notes and e-mail, which all physi-
cians can access.
However, while almost all PCPs use
the computerized record regularly, specialists often do
not. Communication at the time of referral at our institu-
tion relies on dictated notes, e-mail notes, or direct per-
sonal communication between providers that is not com-
puterized. These interactions occur at the discretion of
We conducted 2 types of surveys. First, we performed
a mail survey that asked providers about their satisfac-
tion with the referral process, the major problems with
the system, and what they felt was important content to
convey in referral letters. However, we were concerned
that providers might selectively remember referral in-
stances in which communication had been poor and over-
emphasize certain cases. Therefore, to reduce recall bias
we performed a second e-mail survey in real-time, in
which we asked providers about specific individual refer-
rals (referenced by date of visit and patient information).
The goal was to obtain detailed, concurrent, referral-
specific information about actual communication (see below).
over 400 specialists who practice in the Boston area and
are affiliated with our institution (both on-site and off-
site). We mailed one survey to all 84 PCPs (including both
on-site and community-based physicians), and a slightly
different instrument with specialty-related questions to
405 specialists. The PCPs were all attending-level physi-
cians. Specialists were selected for the survey if they had
received more than ten managed care referrals within the
past 2 years. We sent follow-up letters to all physicians
Physicians studied included 84 PCPs and
who had not responded after 4 weeks. The survey was
performed from September to November of 1997. The re-
sponse rate was 57% for PCPs and 51% for specialists.
overall referral process and physician satisfaction with
the process. Questions about satisfaction were on a 1 to 5
very dissatisfied, 2
neither satisfied nor dissatisfied, 4
very satisfied). Questions about the frequency of
various activities were also scored on a 1 to 5 scale (1
a few times, 3
always). Questions about the importance of in-
formation used a 1 to 5 scale as well (1
somewhat unimportant, 3
somewhat important, 5
Questions to determine how often information was in-
cluded in notes also used a 1 to 5 scale (1
usually [50%–75%], 5
Questions to PCPs and specialists were virtually identical,
with “mirror image” wording.
We used a confidential mail survey to assess the
most of the
neither unimportant nor
almost always [
referral visits by new patients to orthopedics, cardiology,
and gastroenterology. These specialties were chosen be-
cause of their high volume of referrals. The day after the
visit occurred, an e-mail message was sent to the special-
ist. The e-mail had the patient’s name, date of visit, and
PCP at the top, and the survey questions below. If there
was no response within 3 days, a repeat survey was sent.
Two weeks after the referral visit, the PCP survey was
sent. The e-mail included the patient’s name, date of visit,
PCP name, and the survey questions. Again, if there was
no response within 3 days, a repeat survey was sent. If
the PCP had not received information at two weeks, the
same survey was sent again at 4 weeks (again, with a 3-
day repeat if necessary).
Data were collected from May to July 1998. The re-
sponse rate for specialists was 53%; the response rate for
PCPs was 56% at 2 weeks and 70% at 4 weeks. In addi-
tion, for each referral, patient information was collected
from the electronic medical record (age, gender, race, and
An automated program was created to detect
nication between PCPs and specialists regarding specific
referrals, we created a confidential real-time e-mail survey
to send to both sets of providers. Each e-mail survey ref-
erenced a specific referral visit that had occurred. Surveys
were very brief (4 questions) and had yes/no responses.
Respondents could complete and return the survey within
e-mail. Surveys to specialists asked, for a specific referral
visit, whether they had received a referral letter prior to
the visit and whether they had all the necessary informa-
To obtain more concurrent detail about commu-
Gandhi et al., Communication Breakdown
tion (problems to be addressed, questions to be an-
swered). Surveys to PCPs included whether they had
heard back from specialists about specific referrals and if
their clinical questions were answered.
Satisfaction was defined as a reported survey re-
sponse of either 4 (somewhat satisfied) or 5 (very satis-
fied). Dissatisfaction was defined as a reported survey re-
sponse of either 1 (very dissatisfied) or 2 (somewhat
dissatisfied). Responses from PCPs and specialists were
grouped and averaged using the SAS program (SAS Sys-
tems, Inc., Cary, NC). Student’s
appropriate were performed to compare PCP and special-
Mail Survey Results
30 (63%) reported they were dissatisfied with the current
managed care referral system. While PCPs were more of-
ten dissatisfied with the process than specialists (
.001), 35% of specialists were also dissatisfied.
The PCPs said that the 3 biggest problems with the
current referral system were lack of timeliness of informa-
tion from specialists, redundancy of the current process,
and time required to create adequate referral notes (Table
1). Specialists reported that the 3 biggest problems with
the current referral system were lack of timeliness of in-
formation from the PCPs, time required for medical man-
agement or insurance approvals, and lack of clarity of
note content from PCPs.
Of the 48 PCPs who responded,
Method of Information Exchange.
of PCP communication with specialists were letters (40%),
followed by computerized notes (33%) and e-mail (28%). Spe-
cialists also reported communication via letters (73%), com-
puterized notes (47%), and e-mail (24%).
The most common forms
Content of Information Exchange.
tion they provided to the other group (Table 2), 28% of
PCPs and 11% of specialists were somewhat or very dis-
satisfied. Primary care providers were significantly more
often dissatisfied (
.005). In addition, 28% of PCPs and
Regarding the informa-
43% of specialists were dissatisfied with the information
received from the other group. On average, specialists re-
ported that they did not receive enough information to ad-
equately address the problem 23% of the time. Primary
care providers said that 19% of their referrals were “re-
peat referrals”—referrals that had to be repeated because
the patient’s problem was not addressed completely dur-
ing the initial visit.
Specialists reported that the most important informa-
tion they needed from PCPs was problems to be ad-
dressed, clinical questions to be answered, details the pa-
tient was unable or unlikely to provide, medical problems,
and medications. However, PCPs often do not include this
information (Table 3). For example, 74% of PCPs stated
that they often do not include medications, and 68%
stated that they often do not include medical problems.
Primary care providers felt that the most important infor-
mation they want from specialists is answers to specific
questions, the specialist assessment of the patient, re-
sults of tests and procedures, and therapy proposed or
initiated. A substantial percentage of specialists often
omit this information as well (Table 3).
Timeliness of Information Exchange.
of specialists were dissatisfied with the timeliness of infor-
mation from PCPs (Table 2), and 50% of PCPs were dissat-
isfied with the timeliness of feedback from specialists.
Specialists stated that they responded to PCPs within 7
days of the patient’s visit 87% of the time; in contrast,
PCPs reported that only 36% of the time did they receive
follow-up within 7 days.
E-mail Survey Results
Content of Information Exchange.
rals for which specialist responses were obtained. Of these,
53 were from gastroenterology, 37 from orthopedics, and
15 from cardiology. Overall, 68% of specialists reported
that they did not receive prior information from the PCP,
and 38% of these reported that this information would
have been helpful. No substantial differences were found
between specialties. Specialists who did not receive prior
communication were less likely to report that they knew
the problem to be addressed, the question to be an-
swered, or that they had received all the patient informa-
tion they needed (Table 4) (all
There were 105 refer-
.05). No significant rela-
Table 1. Most Significant Problems with the Current Referral Process
Primary Care Providers
a Problem Specialists
Timeliness of information from specialists
Redundant aspects of the current process
Time required to create an adequate referral note
Difficulty in finding a specialist
Lack of knowledge of role of medical management
Time required for medical management approvals
Timeliness of information from PCP
Time required for insurance approvals
Time required for medical management approvals
Lack of clarity of note content from PCP
Time required to create an adequate note for PCP
Redundant aspects of the current process
Volume 15, September 2000
tionship existed between specialty type and receipt of
letters. However, specialists in cardiology and gastroen-
terology were more likely to send letters than orthopedic
Timeliness of Information Exchange.
ferrals from PCPs to specialists that had PCP responses
by e-mail. Two weeks after the referral visit, 40% of PCPs
had received no information from the specialists. Four
weeks after the referral visit, 25% of PCPs still had not re-
ceived any information from the specialist. Patient demo-
graphics (age, gender, race) and managed care insurance
status did not affect whether PCPs or specialists received
There were 112 re-
In this study, we found that both PCPs and special-
ists at our institution were dissatisfied with the current
referral process. We surveyed providers for general im-
pressions of the referral process and with regard to spe-
cific referrals, and found issues of inadequate referral
content and timeliness in both. The referral-specific data
obtained by e-mail survey were remarkably congruent
with the mail survey information. A key issue was the
large discrepancy between what both groups of physi-
cians thought was important information to convey and
what they were actually communicating. In addition, key
barriers to communication were identified, such as time
to create an adequate note. Interestingly, patient factors
and managed care insurance type were not associated
with receipt of information, perhaps demonstrating that
the problem is with the referral system as a whole. Like
many other systems in medicine,
consciously designed and leaves much to be desired.
These data suggest that systems to improve the transfer
of information from PCPs to specialists and vice versa
could improve the quality and efficiency of care for pa-
tients that are referred.
Communication issues are important for physician
satisfaction and for quality of care. Physicians making re-
ferrals have switched hospitals and specialists because of
In addition, physicians who re-
ceived feedback were the most satisfied with communica-
tion from consultants and with the care their patients re-
Finally, improving communication before referral
visits occur can reduce inappropriate referrals.
making the communication system more functional and
precise could improve both physician satisfaction and the
quality of care.
A critical component of effective referral communica-
tion is the referral letter. Both PCPs and specialists were
dissatisfied with the content of the letters they provided
each other and with the information they received. There
were many items that specialists wanted to know that
PCPs said they often did not include. This problem is not
likely to be due to a lack of understanding about what is
important to specialists, given the known consensus
about note content previously demonstrated between gen-
eralists and specialists.
Therefore, the lack of inclusion
of important information is more likely due to time pres-
sure. Both groups reported that the time required to cre-
this system was never
Table 2. Dissatisfaction with Information Content and Timeliness of the Referral Process
Primary Care Providers (%)Specialists
Dissatisfaction with content of information they provided*
Dissatisfaction with content of information they received
Dissatisfaction with timeliness of information they received
Table 3. Information Providers Want and Percentage of Providers who Report Sending this Information
Most Important Information Specialists Want from PCPs
% of PCPs that Report Sending This Information
75% of the Time
Problems to address
Questions to answer
Details patient is unable or unwilling to provide
Most Important Information PCPs Want from Specialists
% of Specialists that Report Sending This Information
75% of the Time
Answers to specific questions
Specialist assessment of patient
Results of test and procedures
Therapy proposed or initiated
Gandhi et al., Communication Breakdown
ate adequate notes was an important barrier. It has been
shown that the quality of consultant reports increases di-
rectly with the amount of referral information originally
Therefore, inadequate notes as perceived by
both the PCPs and specialists in this study are likely to
impact on the quality of the referral process. Interven-
tions designed to streamline the referral process as a
whole and to reduce the time required to create notes
could improve the quality and content of notes.
Specialists were also dissatisfied with the timeliness
of information they received, and 68% reported that they
did not receive information before the referral visit. There-
fore despite technological advances in communication
(e.g., e-mail), we found that a large percentage of patients
were referred without communication between providers.
In addition, only approximately 25% of providers were us-
ing e-mail for referral communication. Not surprisingly,
specialists who did not receive referral communication
were significantly less likely to know what problems and
issues caused the referral. Inadequate letter content and
poor timeliness could account for the substantial percent-
age of specialists who did not have enough information to
adequately address the problem. This in turn could lead
to additional visits or redundant testing, and therefore in-
creased costs. From the patient’s perspective, the current
system is hard to defend. Also, PCPs reported a 19% re-
peat referral rate due to problems not completely ad-
dressed at the first visit, some of which may be related to
inadequate initial communication. Thus, both cost sav-
ings and better quality of care could result from improved
referral note content and timeliness.
Similarly, PCPs were dissatisfied with the timeliness
of communication. Four weeks after the referral visits,
25% of PCPs had not received information from special-
ists. Greater knowledge of consultation results could pre-
vent time-consuming phone calls and could improve sub-
sequent PCP-patient interactions. In one study, receipt of
feedback from specialists was strongly related to commu-
nication by the PCP to the consultant at the time of refer-
ral. Referring physicians who personally contacted con-
sultants or who supplied them with significant clinical
information were more likely to learn the results of the
This effect suggests that interventions to
facilitate communication could have a major impact on
the quality of the referral process.
In managed care environments, facilitating and im-
proving the referral process is essential to maintaining
the referral base of the organization and practicing cost-
effective medicine. One study showed that communica-
tion between primary care and specialist physicians may
be impaired when multiple health insurance plans with
restricted panels of participating physicians are imple-
mented in communities.
In that study, physicians re-
ported that for managed care patients, they were less
likely to know the specialist, to speak personally with the
specialist, or to send a written summary to the specialist.
So-called integrated delivery systems have an obligation
to invest in systematic communications programs to en-
sure proper flow of information between physicians and
One limitation of this study is that it was based at a
single large tertiary care teaching and referral center. The
problems faced by physicians at this site are likely very
different from the challenges at smaller institutions. Both
PCPs and specialists stated that system redundancy was
an important problem. As referral processes become more
complicated due to the complexity of health care plans
and approval processes, medical centers of all sizes need
to create systems that work smoothly and efficiently in or-
der to minimize the clerical work of physicians. Large cen-
ters with more complicated referral patterns and adminis-
trative systems may find this especially challenging. A
second potential limitation is respondent bias, particu-
larly given our response rates. Physicians who were more
dissatisfied may have been more likely to answer the sur-
vey. However, this still means that a large percentage of
physicians in our system are clearly dissatisfied. It is un-
likely that physicians who are poor communicators would
have been more likely to respond to the surveys. There-
fore, the issues of dissatisfaction and inadequate commu-
nication cannot be ignored.
In summary, communication between PCPs and spe-
cialists during the referral process is often inadequate
both in terms of quality and timing, physicians are dissat-
isfied with the process, and physicians identify several
important barriers to communication including time re-
quired to create adequate notes and redundant processes.
Communication needs to be examined in greater detail to
determine ways to improve it. Potential strategies include
automating referral communication and letter generation
through computerized referral applications. We are cur-
rently in the process of developing this kind of system.
Future studies will examine whether improving communi-
cation can result in better patient outcomes, patient sat-
Table 4. Specialist Knowledge of Referral Issues
Specialist Received Prior
Communication, % (n
No Communication Prior to
Referral, % (n
Knew problem to be addressed
Knew question to be answered
Had all patient information needed for the referral
JGIM Download full-text
Volume 15, September 2000
isfaction, and resource utilization. Systems that can facil-
itate referral communication are likely to make the process
more effective for both physicians and their patients.
The authors would like to thank Erin Hartman for her review of
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