This literature review provides the context of the referral process with emphasis on the changes and modifications that can be made to the current model. The main parts of this section are based on the works of previous scholars which has already been published in peer-reviewed journals.
The Referral Process
According to Eskin (2013), the referral process is the activity of transferring patients from one medical practitioner to another. This act of referral can be a request made by patients, their families, hospital management, or practitioners themselves (Lamb et al., 2018). It is already estimated that more than 40% of primary care practitioners receive patients through referrals in public hospitals across the world every year (Poksinska & Engstrom, 2017). Research conducted by Naiker et al. (2018) shows that there are three main reasons practitioners may prefer to refer their patients to other specialists.
One of the reasons is when physicians cannot treat a patient. As indicated by Beernaet et al. (2015), there are times when a physician is unsure of the correct diagnosis to make. At such moments, and in the best interest of the patient, it is advisable that the sick person is transferred to another specialist (Smith et al., 2014). The second reason is when the physicians feel that there is a need for another opinion (Miller-Matero et al., 2016). This often happens when the patient has a risk factor, and a doctor wants to be sure before continuing with the diagnosis or treatment (Livingstone & Solomon, 2018). The third reason is when the physician wants to improve patient access. Patient access, in this case, may refer to the location when patients are assigned to practitioners near to their places of residence (Naiker et al., 2018). This could also happen when a patient is sent to a more accessible physician or one that speaks a common first language (Hewett, Watson & Gallois, 2016).
Barriers to the Referral System
Health care units are designed to assist patients to receive medical care at the primary care level, and if the need arises, they can be referred to a higher level (Kielich et al., 2017). For this reason, a referral is one of the crucial aspects of every health system as it ensures continuity of patient services (Mitchell, 2014). In research by Tuot et al. (2015), the authors identify that up to 68% of the patients in the primary care facilities are referred to another specialist every year. However, only 36% of these patients are able to access efficient referral services (Husman, 2014). The differences in these two statistics are indications that there are gaps in the transfer system (Lindvall, Hultman & Jackson, 2014).
According to Vargas & Silva (2016), the rising cost of transfer services is one of the most significant barriers to the current patient transfer model. Given that the patients are in different economic levels, it means that not all of them would be in a position to afford the high cost of referral services (Semmens et al., 2015). Another challenge is the lack of adequate knowledge among the physicians on the referral process. A study on the process by Cazap et al. (2016) reveals that an estimate of 20% of primary care providers does not know when to refer their patients to another specialist. In a different study, however, Wiese & Freeman (2013), argues that most physicians undergo numerous training and therefore, inadequate knowledge cannot be blamed for the failed referral system. The barrier is further supported by Walker (2015), who finds that at least one out of every three physicians in public health centers lacks sufficient knowledge of the referral process. In this case, insufficient knowledge on the part of physicians has a direct impact on the referral process.
The next challenge is the lack of connection between the different levels in the referral process. This barrier is often caused by a communication breakdown between the physician and the specialists (Trude & Stoddard, 2013). When the primary care practitioners have unclear reasons for a referral, they often give inadequate or incomplete information to the specialist who might not be able to make the correct diagnosis (Scott & Ward, 2016). The same also happens when the specialist fails to provide the proper feedback to the physician (Rechel et al., 2016). As explained by Vermeir et al. (2015), such communication issues are associated with the current paper referral system, which is faced with delays. In this case, such a barrier could be minimized by adopting electronic health records which ease communication between the physicians and the specialists typically.
Another barrier to the system is the self-referrals. Self-referrals refer to situations when patients take themselves to specialists on their own choice (Brown et al., 2014). While this kind of decision enables patients to receive referral services at their convenience, it is also a challenge because most patients have inadequate knowledge of their condition or the referral system (Geta, Belete & Yesuf, 2019). Scholars have different opinions concerning self-referrals. Moljord (2016), argues that in the wake of increased specialized services, patients are bound to refer themselves to specialists of their own choice. With such services, some patients feel no need to visit the primary practitioner and directly refer themselves to specialists. (Fleegler et al., 2016) However, warns against such tendencies citing lack of enough information on the patient side. Such issues can be reduced by adopting the electronic system, which makes the referral process more effective (Holman et al., 2017).
Changes to the Patient Referral System
One of the most significant aspects of every health system is that it should be able to suit the needs of the patients and within a time frame that a patient needs its services (Kraaijvanger et al., 2016). As a result of delays which have been listed above, there is a need to revamp the current referral model so that it can effectively meet the needs of the modern day patients (Cheng et al., 2015). One of the changes is to ensure that public hospitals are linked up to several insurance firms (Cook et al., 2017). This would ensure that patients, regardless of their insurance provider, can be able to access referral services (Vimalananda et al., 2015). Since the biggest problem facing the referral process is inadequate finances, increasing the scope of insurance services would ensure that more patients receive the service (Ramelson et al., 2014). Additionally, the governments, through the lawmakers, can enact laws that would stipulate the amount to be paid by patients in a referral system (O’Malley et al., 2015). This would consequently reduce the cost of the services (Nolan, 2014).
The next change is to enhance the sharing of information among various constituents in the system. According to Pelletier & Stichler (2014), communication breakdown is a significant challenge to the success of referral systems. This can be reduced by creating and keeping updated patient data that can be shared among physicians and specialists (Zuchowski et al., 2015). Additionally, health care units can create electronic patients directory that would contain all the medical information about specific patients (Ramanayake, 2013). Such databases would increase efficiency and improve the outcome of the care system (Singh et al., 2015).
From the information given above, there is no doubt that the current system is marred by a lot of inefficiencies. To improve the quality of care, specialists have tried to come up with alternatives to the current system (McGorm et al., 2016). In most of the public hospitals, physicians write referral letters, which are then given to the patients (Berendsen et al., 2017). In other cases, patients are given business cards with the contact and address of the preferred specialist (Coulter, 2015). Most of these methods have been mostly ineffective, raising the need to create more a more efficient model. According to Naseriasl, Adham & Janati (2015), all the challenges in the current model can be solved by adopting E-referral system.
The e-referral system is an electronic model where all referral services are conducted via the web (Bestell et al., 2014). It ensures that primary care units have internet forms where all the referral requests are filled and electronically sent to the next practitioner (Reinhart et al., 2013). The model is meant to replace the current method of sending requests via fax or telephone (Esquivel et al., 2015). The web-based forms are well structured, indicating the condition of the patient and the reason(s) for a referral (Kim et al., 2016). This, according to Bodenheimer (2018), reduces the problem of unclear guidelines since all the details are covered in the forms.
One of the most significant benefits of the E-referral system regards to its efficiency (Ridsdale et al., 2017). According to Ahmed et al. (2019), all the information entered into the system is accurate and is delivered on time. This helps in reducing the problems of delayed services which have rocked the health sector for an extended time (Nadeem et al., 2018). Additionally, hand-written letters or sent faxes may be hard to track and analyze (Vermeir et al., 2015). As a result, much of the information in the current model ends up getting lost meaning that the specialists are not in a position to make informed judgments (Maghsoud et al., 2017). The condition is, however, solved by the electronic system, which makes it easier to track and follow up patient information (Sampson, Barbour & Wilson, 2016).
According to Tian (2016), E-referral system is useful because it increases the ease of access. The system contains all the information about the specialists, which can be easily accessed by primary care practitioners (Maatz et al., 2016). In this way, physicians are in a position to refer their patients to the available specialists and thus reducing delays that may be caused by physically searching for the available practitioner (Barnett et al., 2016). Additionally, the system has automated notifications that enable both and secondary practitioners to follow the progress of the patients (Shepherd et al., 2018). Given the importance of communication in the referral system, there is no doubt that the E-system would be the most viable solution to the challenges facing the current model (Patel et al., 2018).
Current research done by Liddy, Drosinis & Keely (2016) reveals that the electronic model improves not only the patient services but also the quality of the entire health system. As a result, the patients and the general public would have confidence in the system, and this would improve the relationship between the patients and the practitioners (Wilson et al., 2016). Therefore, as we chart towards the future, there is a need to adopt a model that can cater to the needs of the highly diversified patient population on time (Patel et al., 2018).
Managing Specialists’ Opinions
In every health system, patients are sent to specialists either for further treatment or to generate another opinion concerning the ongoing treatment and the state of the patient. Due to the position they occupy in the clinical hierarchy, specialists have the upper hand in the treatment of the patients (Starfield et al., 2015). Often, the recommendations made by this group of practitioners determine the direction of the treatment. Various studies have been conducted to establish how well the opinions can be managed for quality care. A study by Rosenwax et al. (2016) reveals that more than half of the physicians rely on specialist opinion to make their decision about treatment.
A research conducted by Turner et al. (2016) shows that only 35% of the specialists can be reached through telephones for consultations with the physicians. This means that the majority of physicians have to rely on written records to make their diagnosis (Gullick et al., 2016). Evidently, inadequate information results in poor treatment and thus poses a threat to the lives of the patients. Managing specialist opinion and feedback, in this case, means ensuring that the relevant medical information is provided within the required timeframe (Brookes et al., 2014).
According to Endsley & Wright (2017), it might be difficult for the management to follow up every referral document made by the specialists to ensure that it fits the standard. This is further complicated by the presence of many patients, all of whom require specialized care (LoBiondo & Haber, 2017). The approach, in this case, is to ensure that the management implements a system that would enable them to oversee the referral process with ease. To improve the feedback, Peacock & Kelly (2014) recommends that the health centers adopt the electronic referral system. The E-referral system would reduce not only delays associated with specialist feedbacks but also minimize the cases of missing information (Bradford, Caffery & Smith, 2016). With this kind of a system, specialists will be a position to follow the progress of the patients and offer additional support to the physicians (Moffat & Eley, 2015).
The next way of managing specialist services is ensuring that the specialists are relocated to the primary healthcare units (Walker, 2015). Under this arrangement, every health center should have its own set of specialists who can be easily accessed by both the physicians and the patients (Frow, McColl & Payne, 2016). This kind of plan would reduce the struggles experienced by the physicians as they try to locate and book appointments with the specialists (Garman et al., 2014). As a result, this would reduce transportation costs incurred by patients and fasten the process of service delivery. Additionally, having specialists in primary care settings would be beneficial to the physicians as they would get a chance to learn from the former (Ivers et al., 2015).
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