LETTER TO THE EDITOR
To the Editor: Ð In the recent article by Ghandi et al.,
entitled ``Communication Breakdown in the Outpatient
Referral Process,'' the authors discuss many issues that
primary care providers (PCPs) and specialists face in the
referral process which make effective referral communica-
As noted by these authors, even with
technological advances, rates of worthwhile communica-
tion and satisfaction have not substantially changed. The
system of care described in the article was a large tertiary
care teaching and referral center. An article from the
pediatric literature describes success in the referral process
if the pediatrician communicated with the specialist prior to
the scheduled specialty appointment.
At our integrated
health system, an urban acute care hospital, vertically
connected with multiple primary care sites located through-
out the city, we recently found that the rate of communica-
tion from specialist back to referring physicians was only
34.7%. This disappointing result occurred despite specia-
lists being aware of two prior studies at our institution in the
last three years which showed poor rates of communication,
as well as directives from hospital administration which
exhorted the staff to improve this communication process.
The first two studies demonstrated a 17.6% and a 29.1%
rate of referral communication completion between the
specialist and the referring PCP, respectively.
As discussed by Ghandi et al., the problem of
effective communication in the referral process is com-
plex. It requires more than ``report cards'' of communica-
tion rates, more than technological advances and more
than an awareness by physicians of what comprises
acceptable referral letters and acceptable specialist com-
munication of findings to the referring physician. An
additional obstacle present in systems of salaried employ-
incentives to participate in a time-consuming, yet im-
portant, patient care area such as referral communica-
tion. One necessary part of involvement is a streamlined
referral communication system to avoid the potential
adverse outcomes from breakdowns in coordination of
We suggest that a system-wide incentive, of
some type, might also enhance participation in the
communication process from the specialist to the PCPs,
which has been reported to be low for many years.
, MD, and P
Health, Denver, Colo.
1. Ghandi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG,
Bates DW. Communication breakdown in the outpatient referral
process. J Gen Intern Med. 2000;15:626±31.
2. Forrest CB, Glade GB, Baker AE, Bocian A, Schrader S, Starfield
B. Coordination of specialty referrals and physician satisfaction
with referral care. Arch Pediatr Adolesc Med. 2000;154:499±506.
3. Epstein RM. Communications between primary care physicians
and consultants. Arch Fam Med. 1995;4:403±9.
4. McPhee SJ, Lo B, Saika GY, Meltzer R. How good is communica-
tion between primary care physicians and subspecialty consul-
tants? Arch Intern Med. 1984;144:1265±68.