Advance your referral intelligence

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Apr 11, 2018

When healthcare providers refer their patients to another physician or surgeon for evaluation and management of a specific medical problem, the process for how that referral becomes an actual visit with the specialist varies quite a bit.


The referral process can be as low-touch as giving the patient the specialist’s name and phone number, or as high-touch as the referring provider’s care coordinator working with the patient and the specialist’s office to find a convenient appointment time and location, ensure the evaluation will be covered by the patient’s insurance plan and send any necessary documentation in advance of the consult.

Evaluating referral patterns

While the process of a referral actually becoming a consultation can vary quite a bit, how providers decide to whom to refer their patients to usually doesn’t: they typically refer to the same specialists and groups that they always use, much like how people order the same meal or two when they go to a particular restaurant.


How providers decided to use those specialists in the first place was typically based on fairly subjective criteria, such as their office partners use them, they live down the street or go to church with them, they hear good things from colleagues and patients, etc.


Now to be fair, until very recently, there hasn’t been a more objective way to decide which specialists should see patients, so providers had to base their decisions on available information. Whether it is your go-to general surgeon or how you order your steak, it’s easy to fall into habits.


Fortunately, we increasingly have the ability to make intelligent referrals based on pertinent and more objective data, with an ultimate goal of referring a patient to the specialist who is most likely to deliver timely, high quality and cost-effective care and to offer the patient a good experience along the way.


With access to this type of actionable information, providers may change (or affirm) their habitual referral patterns to ensure that their patients are seeing the best specialists for any given reason.

Injecting referral intelligence

There are two ways providers’ referral choices can be influenced by objective data. The first is as the provider is in the process of ordering the referral, and the second is during a conversation about referral patterns outside of the clinical work flow.


When a provider is seeing a patient and decides that a referral is needed, he or she is likely pressed for time and wants to set the referral in motion and move on. For this reason, the point-of-care is not a time for thoughtful consideration of how you decide who receives your referral, rather it is a time when clearly presented, high-impact information can influence choices.


For example, when presented with information about long wait times for an appointment or negative patient ratings for a specialist, the provider can quickly digest that type of information and perhaps select another specialist with more availability or better patient ratings. Clearly presented information about whether the specialist is in-network and participates with the patient’s health insurance plan can also quickly influence referral choices during patient care workflow.

New drivers of referral patterns

Other types of information have the ability to influence referral patterns during a meeting with providers outside of their clinical time. In addition to reviewing leakage/keepage reports and comparisons with other providers, this is a time to review which specialists are in- and out-of-network.


This is also a time to review available clinical and cost of care information about various specialists and to discuss whether this information and a provider’s historical referral patterns are aligned. This type of thoughtful consideration of the best specialists for certain types of medical conditions requires some time and active discussion, so it is best done outside of patient care time.


This review and conversation also likely has the chance of making the most meaningful impact on referral patterns, with respect to clinical and financial outcomes and patient satisfaction.


The decision making for any given referral has many variables, and fortunately for patients, we are increasingly able to base those decisions on meaningful information of practical value to help make intelligent referrals to the specialists most able to deliver the best possible care for patients.

About the author

Paul Taylor

Paul D. Taylor, MD, 
CMO, Philips

Paul D. Taylor is CMO for Philips PHM. Board-certified Internal Medicine physician and entrepreneur with experience developing industry-leading Value-Based Care and Population Health Management solutions and implementing clinical quality improvement programs and systems of care at the physician, physician group, physician organization, and community levels.

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