Patient referral leakage: Are health systems making it easy to do the right thing?

I recently spoke with a colleague about a large hospital client which is examining how they can reduce their patient referral leakage. By referral leakage, I mean patients who get primary or emergency care from a doctor at one health system who then seek specialty outpatient care from a clinician at a different health system. On a slightly sarcastic sidenote, I think it is fun when we use terms like “leakage” to describe business-related concepts. Let’s be honest and agree that when “leakage” is discussed with a healthcare focus, most of us think of something completely different. For reference, please see shrinkage and breakage, which absolutely do not mean what you think they mean when used in a business context.

It is worthwhile to consider whether patient referral leakage is even something we can discuss in mixed company. Is it ethical for a healthcare system to try to minimize leakage? From a financial standpoint, it certainly makes a lot of sense. Leaders estimate that they may lose up to 10-20% of potential revenue when patients seek specialty care or testing elsewhere. I’m no accountant, but that seems like a lot of money. Naturally, physicians and hospitals need to always focus on patient care and quality, yet the truism of “no margin, no mission” always looms prominently in the background.

It is reasonable to assert that a health system that is truly “systematized” (as opposed to a bunch of clinics and hospitals that operate independently yet share the same logo and exterior paint color) can both save money and maximize quality. When a patient leaves a health system with a unified electronic health record (EHR), they risk their “outside” doctor re-ordering lab or imaging tests because the results couldn’t be easily accessed (NB: interoperability is a work in progress!). While some documentation may accompany the patient to the specialist, it is often basic and lacks important details and context. Keeping patients within their home health system – assuming their care requires services that are offered internally – seems like a good idea from both the financial and clinical perspectives.

Those of us who have graduated from medical school tend to be very competitive ...

How does a health system minimize referral leakage? Often, they try to convince their physicians of the benefits of offering specialty care within the system. This involves conversations with operational leaders who may meet with doctors individually to review “their numbers” and discuss specific patients who were sent elsewhere but could have been cared for internally. Perhaps physicians will be presented with the percentage of their patients who seek care at another system, comparing their percentages with peers in the same clinic. Those of us who have graduated from medical school tend to be very competitive, so presenting us with “comps” can be quite effective.

Unfortunately, some health systems overlook what might be the most significant cause of their patient referral leakage: their EHR is not configured to make it easy to do the right thing. If the “right thing” is sending the patient to a specialist in the same system, then the tool that docs use to make that happen should be set up to make that happen with the least amount of friction. No duh, amirite? Yet, this is often not the case.

Typically, physicians order referrals in the electronic health record. Once you have seen how one health system configures a particular vendor’s EHR for referring, you have seen how one health system configures a particular vendor’s EHR for referring. In other words, it is a jungle out there. There are different boxes and buttons and required fields. Routinely I see generic referral orders being presented to physicians, which means that every time they want to send a patient to a specialist, they need to check boxes, select dropdowns, and click around. This is not ideal.

To help doctors do the right thing (i.e., refer internally if in-system clinicians can address the patient’s needs), the EHR ordering process should default to internal referral. Does this mean the physician must keep the patient inside the health system? Absolutely not. The usability principle of keeping it easy to do the right thing has a corollary: make it possible, but slightly difficult, to do the wrong thing. The doctor can always write for an external referral, but it should be one click away. The default order should be for an internal referral, but an external referral is always within reach for the minority of patients who would benefit from seeking specialty care outside the health system.

In my experience, those who are responsible for quality or financial metrics at large health systems often forget to ensure that their colleagues follow basic usability principles. Once we have determined what the “right thing” is, make that the default and the path of least resistance. Of course, this is true for technology tools such as the EHR, but also for operational workflows. The entire “lifespan” of the process by which a patient is referred to a specialist should be focused on ensuring that the right thing happens every single time. It sounds easy, and it sometimes is, but only if enough time and energy are expended to ensure success.