Communication Disconnect Between Primary Care and Specialist Physicians

Overview

When a primary care physician refers a patient to a specialist, a chain of communication should follow: the specialist needs the patient's history and the reason for the referral, and the referring physician needs the specialist's findings and recommendations. In theory, this exchange is routine. In practice, according to a national study by the Center for Studying Health System Change (HSC), primary care physicians and specialists have strikingly different perceptions of how often this information actually changes hands.

Published in the January 10, 2011 issue of Archives of Internal Medicine and funded by the Robert Wood Johnson Foundation, the study by Ann S. O'Malley, M.D., M.P.H., and James D. Reschovsky, Ph.D., drew on HSC's 2008 nationally representative Health Tracking Physician Survey, which collected responses from 4,720 practicing physicians at a 62 percent response rate.

The Perception Gap

The central finding was a large disconnect between what physicians said they sent and what their counterparts reported receiving. Nearly 70 percent of primary care physicians (PCPs) said they regularly — meaning "always" or "most of the time" — forwarded a patient's medical history and the reason for the referral to the specialist. Yet only about 35 percent of specialists reported regularly getting that information. The gap ran in both directions: more than 80 percent of specialists said they regularly sent consultation results back to the referring PCP, but only 62 percent of primary care physicians said they regularly received those results.

This mismatch was more than a bureaucratic headache. Physicians who did not receive timely communication about referrals and consultations were significantly more likely to report that their ability to deliver high-quality care was compromised.

Why the Disconnect Matters for Patient Care

Incomplete communication during referrals can have real consequences for patients. When a specialist does not receive the patient's history, there is a risk of duplicated testing, missed diagnoses, or treatments that conflict with the patient's existing care plan. When a primary care physician does not get the specialist's findings, follow-up care may be delayed or mismanaged. Medication changes ordered by the specialist may go unrecognized by the PCP, creating opportunities for drug interactions or dosing errors.

The problem is compounded for patients with chronic conditions who see multiple specialists. Each additional provider in the care team represents another link in the communication chain that can break down. For these patients, fragmented communication can undermine the coordination of care that is most needed.

What Explains the Gap?

Several factors may account for the difference between what physicians said they sent and what their colleagues reported receiving. Information sent by fax or mail may be lost in transit, misfiled, or simply never reach the intended recipient's desk. Referral letters may be prepared by office staff but never actually transmitted. In other cases, the information may arrive but not be reviewed by the physician, particularly in busy practices where incoming documents pile up.

There is also the possibility of optimistic self-reporting — physicians may overestimate how consistently they share referral information, while their counterparts give a more accurate accounting of what they actually see arriving in their offices.

Factors Linked to Better Communication

Despite the bleak overall picture, the study identified conditions under which referral communication improved. The single most powerful factor for both PCPs and specialists was having adequate time to spend with patients during an office visit. Physicians who felt less rushed were far more likely to report both sending and receiving referral information.

Practice-level supports for care management also mattered. Physicians who received feedback reports on the quality of care for their patients with chronic conditions, and those whose practices employed nurses to monitor chronically ill patients, reported better communication in both directions. These structural supports appeared to create an environment where information-sharing was more systematic rather than ad hoc.

Health information technology showed a more mixed picture. The use of electronic health records and other health IT was associated with higher rates of sending and receiving communication among specialists, but the same association did not hold for primary care physicians. This may reflect differences in how PCPs and specialists used available technology, or it may indicate that the technology solutions available at the time were better suited to specialist workflows.

Implications for Health System Design

The findings carried direct implications for the design of health care delivery systems. The strong link between adequate visit time and better communication suggested that payment models pushing physicians toward ever-shorter appointments were working against effective care coordination. Likewise, the positive role of care management infrastructure argued for investment in nursing support and quality feedback systems as practical tools for improving the referral process.

The study also raised questions about the push for health information technology as a standalone solution. While health IT clearly had potential to improve information exchange, the results suggested that technology alone was not sufficient — organizational and workflow factors were at least as important in determining whether patient information actually moved between providers.

"The bad news is that there's a real communication disconnect between primary care and specialist physicians about patient referrals and consultations," said O'Malley. "The good news is that the study identified factors that were associated with better communication between primary care and specialist physicians."

About HSC

The Center for Studying Health System Change was a nonpartisan policy research organization based in Washington, D.C., dedicated to producing objective, timely research on the U.S. health care system for policymakers and the public. HSC was affiliated with Mathematica Policy Research.

Sources and Further Reading

AHRQ — Care Coordination — Federal resources on improving care coordination across providers.

HealthIT.gov — Federal initiatives on health information technology and interoperability.

Commonwealth Fund — Research on care quality, coordination, and health system performance.

Robert Wood Johnson Foundation — Health policy research and programs.

Patient-Centered Primary Care Collaborative — Advocacy and research supporting the patient-centered medical home model.