Did that patient get booked?

Medicine is a team sport. Physicians need to collaborate in order to deliver the best care to their patients. As a result, making and receiving referrals is a big part of every physician’s workday. Choosing the right resource for a patient and, on the flip side, receiving appropriate referrals within one’s scope of practice is so important to deliver efficient and high-quality care. In this article, we will review the current state of physician-to-physician referrals and why this is not working.

A photo of Toronto when using fax machines were popular! (Photo Credit: Taylor on History)

The vast majority of referrals are still paper-based, primarily through fax. This system has several critical failures, namely 1) faxes are not truly tracked in a rigorous way such that it is certain that the fax has been received on the other end ; and 2) verifying with certainty that the recipient on the other end truly is the intended recipient. This isn’t an uncommon scenario but in one case, a clinic had been misdialing the fax number for a mental health practice, and instead referrals were being sent to a private business [2].

So why is this problematic process still in practice? A few recurring reasons mentioned by healthcare professionals themselves include a fragmented EMR market, liability issues related to privacy and security of other methods, difficulty in changing established routine workflows and processes, and the hard fact that virtually every physician, clinic and institution is “reachable” by fax!

Any change or innovation in healthcare needs to win over and modify the very strong status-quo, so it all comes down to one thing. Is this referral system worth changing?

The short answer is yes!

Why should we care?

Due to the nature of faxing, a lot of paperwork and manual work is involved. Unsurprisingly, this causes a number of issues in safety, access and cost:

  1. Fax referrals get lost

This is not just an annoyance for patients and for referring physicians, but consequently can lead to major delays in diagnosis and potential lasting harm to the patient. In the unfortunate case of Greg Price, the string of failures around fax-based referrals led to unnecessarily long wait times, delayed appointments and ultimately contributed to his premature and tragic death.

One study has suggested that many of the preventable errors in medical care are related to the miscommunication between primary care physicians and specialists, with lost referrals being one of the main contributors [3]. Another study showed that the replacement of fax referrals with a web-based communication portal led to major improvements in wait-times and success rate of referrals for an academic institution [4]. For their sample size of around 40000 referrals, 54% of referrals led to scheduled visits before the intervention, whereas there was an 83% success rate after adoption of the web-based system. The median wait-time was 168 days with fax referrals and 78 days after the portal was implemented.

2. Fax referrals contribute to longer wait times

There are many contributing factors to long wait times to see a specialist, but outdated processes are a major one. As a result of the spotty and slow communication between clinics, there is basically no way for the primary care physician to find out which specialist has a shorter wait time to optimize the referral process. This can lead to delayed appointment times that can leave the primary care doctor struggling to manage the patient’s condition while waiting for specialist input. Doctors also often refer their patients to specialists without current information about their scope of practice, i.e. their subspeciality. Those rejected referrals have to then be reprocessed by the primary care physician, that is if the paperwork did not go missing. This process can repeated any number of times, with frustration building on all sides. Worse still is that all this dissatisfaction with the system is preventable.

3. Fax referrals are costly

Primary care clinics are burdened with the challenging task of trying to track referrals and acting as the mediator between patients and specialists . In certain cases, some primary care groups in Canada have spent close to seven figures to hire teams of medical clerks to track referrals and try to contain this problem, but at an enormous cost.

So, the use of a fax causes the system to work inefficiently and as a result leads to appointment delays and long wait times for patients. Like any other industry, technology is proven to improve the efficiency and save costs as well. There are ways to do better so what is stopping us?

In the next article, we will review some of the emerging alternatives in the field and barriers to adoption.

[1] Guerriere, M. (2017, July 28). Beyond the fax machine. Retrieved from https://www.telushealth.co/item/beyond-fax-machine/

[2] Solomon, H. (2016, November 25). Nova Scotia privacy breach shows why faxing personal information must end. Retrieved from https://www.itworldcanada.com/article/nova-scotia-privacy-breach-shows-why-faxing-personal-information-must-end/388727

[3] Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-Off Communications[PDF]. (2012, August). Joint Commission Perspectives.

[4] Michael Weiner et al. (2009, April 15) A Web-based Generalist–Specialist System to Improve Scheduling of Outpatient Specialty Consultations in an Academic Center

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686771/

[5] Examination of Health Care Cost Trends and Cost Drivers[PDF]. (2011, June 22). Office of Attorney General Martha Coakley

[6] https://tayloronhistory.com/category/old-toronto-movie-theatres/



Healthcare, Business and Tech enthusiast. Passionate about arts, food, and road-running.

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Saeed Zeinali

Healthcare, Business and Tech enthusiast. Passionate about arts, food, and road-running.