A Country Doctor Writes:

There’s an incredible confusion in some medical practices about which outgoing orders are referrals and which are not.

According to healthcare.gov, a referral is:

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

As a primary care physician, I can refer a patient to an individual specialist, to a specialty practice without naming the doctor, or to the hospital – often to the emergency room because immediate testing or treatment is needed, sometimes directly to the hosptalist service for admission.

If I order lab work or imaging, those are not referrals, they are orders. The results come back to me and I have to decide what to do with them. Even if a radiologist who interprets an X-ray makes a diagnosis, it is still up to me to make a medical decision as to what to do for my patient. Neither lab or X-ray orders are technically referrals.

Why is this distinction important? Let me tell you a story.

John McCall is a 76-year old man who just had a triple bypass. Almost a year ago I saw him for exertional chest pain that he had had for over a year and it wasn’t getting worse. I put in an order for a nuclear stress test in his electronic chart. It seemed to take an awful long time to get that test results back, but that’s not entirely unusual in a shortage area like where I practice. Resources are few and weights can be long. I wasn’t all that worried because his angina seemed stable, I just wanted to see, roughly, what the extent of his coronary disease was.

I was surprised when I got a fax from the cardiology office. It was a consultation note from a part-time cardiologist in the two doctor office. The conclusion was that Mr. McCall needed a nuclear stress test.

I scratched my head and looked back in his chart. This is what happened. In some hospitals, the X-ray department schedules nuclear stress test because it’s an imaging procedure. In the hospital, John wanted to have the test at, the cardiology office schedules such tests.

In our medical record, we have the option to initiate a referral or the option to initiate an imaging order. The referral template automatically includes patient demographics like address and insurance information. An imaging order does not automatically include that. The referral order also has a text box that states referral for treatment, including consultation visit. The imaging order template has no such phrasing in it. Somebody in my office sent my imaging order to the cardiology department using the template for referral rather than what in my record is called just “provider letter”.

So somebody in the cardiology office saw, presumably, that I wanted a nuclear stress test, but the comment at the bottom of the page about treatment and consultation made them put my patient on the waiting list to see the understaffed cardiology practice for a consultation.

We lost months due to this glitch. Fortunately, his angina remained stable and he had a follow up with the cardiologist after the test was done. It was not considered a high risk scan. Medication was tried, but didn’t make much difference so he ultimately ended up with a locally done catheterization and then referral to cardiovascular surgery in the big city, where he ended up with an uneventful bypass operation.

This could have gone worse, but it is a lesson that referral is the accepted word for requesting a medical opinion, and I feel strongly that it should not be used for a test order where the ordering physician will deal with the results.