Structured printed referral letter (form letter); saves time and improves communication.

Referral of patients to hospitals, specialists and other institutions is an essential part of primary health care. Patients are referred to specialists when investigation or therapeutic options are exhausted in primary care or when opinion or advice is needed from them. Referral has considerable implications for patients, health care system and health care costs. Good communication between primary and secondary care is essential for the smooth running of any health care system. Referral and reply letters are the sole means of communication between doctors most of the time and breakdown in communication could lead to poor continuity of care, delayed diagnoses, polypharmacy, increased litigation risk and unnecessary testing. A referral letter also helps to avoid patient dissatisfaction and loss of confidence in family physician. Studies of referral letters have reported that specialists are dissatisfied with their quality and content. Inclusion of letter writing skills in the medical curriculum, peer assessment and feedback have shown to improve the quality of referral letters. Form letters have shown to enhance information content and communication in referral process. In Sri Lanka referral letters are usually hand written and frequent complaints are that these letters do not contain adequate information and retrieval of information is a problem due to poor legibility and clarity. Sometimes Primary care doctors refer patients to hospitals and specialists with only verbal instructions. To address these short comings this form letter was introduced. Based on the guidelines and systematic review of published articles, items of information to be included were decided. Printed forms of the letter are kept in the practice and the doctor has to just fill up relevant information under each heading. The objectives of introducing this structured referral letter was to improve the quality and standard of referral letters and save time for both general practitioners and specialists.

Introduction

Referral of patients to hospitals, specialists and other institutions is an essential part of primary health care. Patients are referred to specialists when investigation or therapeutic options are exhausted in primary care or when opinion or advice is needed from them. Indication for referral may be routine (cataract), urgent (iritis) or emergency (acute glaucoma). General practitioners/family physicians manage over 95% patient encounters on the average on their own but the remainder requires further resources and expertise.[1]

Idea behind referral is for two physicians with different experience and expertise to communicate with each other in finding a solution for a patient's problem and providing the best possible care at the correct time at the correct place. Referral has considerable implications for patients, health care system and health care costs.[2]

Karunarathna one of the pioneers of family medicine in Sri Lanka described primary care physicians as “doctors who have a large measure of expertise in breath unlimited by age, sex, body system or type of problem (physical/psychosocial)”[1] and referral as “an appreciation of the limitation of their expertise in depth.”[1] She has emphasized that in the process of referral primary and continuing responsibility for the patient should lie with the family physician who is best suited for maintaining continuity and coordination of care.[1]

Communication Between Doctors

Good communication between primary and secondary care is essential for the smooth running of any health care system[3] and it is also vital for a safe and high quality referral process. Breakdown in communication could lead to poor continuity of care, delayed diagnoses, polypharmacy, increased litigation risk and unnecessary testing.[4] Communication between doctors of different experience and expertise is also an important means of education for both.[3]

Often there is no direct contact between primary care doctors and specialists. Even though methods of communication have significantly changed in the past few decades with the advent of mobile phones, internet, email etc., written communication in the form of referral and reply letters are the most common and most of the time sole means of communication between doctors.[5] In fact there is a general acceptance also that communication must be by letter.[6]

Referral Letters

A clear and concise letter with sufficient information will aid the specialist and the patient in many ways. It prevents delays in diagnosis and treatment and reduces unnecessary repetition of investigations and poly pharmacy which will increase health care costs.[5] Such a letter also helps to avoid patient dissatisfaction and loss of confidence in family physician.[3] Apart from conveying information referral letters are a valuable source of reference, evidence of informed consent and a medico legal record.[7] Referral letter reflects the diagnostic skills, communication skills and professionalism of the doctor.[8] Number of studies have revealed an improvement of quality of reply with quality of referral letters.[49]

Studies of referral letters have reported that specialists are dissatisfied with their quality and content.[510] Several studies have revealed frequent absence of an explanation for referral, medical history, clinical findings, test results and details of prior treatment in referral letters.[11121314] At the same time clarity, legibility and overall format are also important features of a good referral letter. Number of authors have mentioned time constraints[14] and lack of secretarial support[3] as reasons for incomplete and badly written referral letters.

Attempts have been made to improve the quality of referrals. It has been suggested to include letter writing skills in the medical curriculum of both undergraduate and post graduate courses.[115] Peer assessment and feedback have been identified to improve the quality of referral letters.[16] Several studies have reported the use of form letters to enhance information content and communication in referral from general practitioners to hospital and medical specialists.[1718192021] Grimshaw, et al., reported that only structured referral sheets and involvement of consultants in educational activities would improve the effectiveness and efficiency of referrals from primary care to secondary care, following Cochrane data base review.[2]

Form Referral letters

Form letters are structured or standardized referral letters which include headings for relevant information. Form letters have been found to be shorter and contain more information than non-form letters.[19] Couper and Henbest reported an improvement in the quality of referral letters after the introduction of a form letter[20] and a few studies revealed that general practitioners preferred structured letters.[182223] Martin and others described the advantages of a structured format for referral and reply letters, which includes easy identification of information desired.[24]

Scenario in Sri Lanka

Sri Lankan health system is such that referral from primary care to secondary care is not essential to consult a specialist. Patients are free to consult a specialist of their choice even for a minor ailment in the private sector. In Sri Lanka referral letters are usually hand written and frequent complaints are that these letters do not contain adequate information and retrieval of information is a problem due to poor legibility and clarity. Another scenario is that primary care doctors refer patients to hospitals and specialists with only verbal instructions perhaps due to time constrains.[1] Use of computers for record keeping or to generate prescriptions and letters is not common and popular among primary care doctors in Sri Lanka yet.

Development of form letter

Based on the guidelines and systematic review of published articles, items of information to be included in the letter were decided.[15712131425] Drawbacks of current referral process and referral letters were taken into account. Expectations of specialists regarding the quality of referral letters were also considered.[510] To minimize the cost of printing, dimensions of the letter were decided so two letters can be printed with an A4 paper [Figure 1]. Printed forms of the letter are kept in the practice and the doctor has to just fill up relevant information pertaining to the patient under each heading. The main objective of introducing this structured referral letter was to improve the quality and standard of referral letters.

Figure 1

Referral form

Advantages of the form letter

This form letter will be of advantage to general practitioners and recipients in many ways.

Saves time of the general practitioners

It is not necessary to plan or think about the format of the letter. It is just filling up details pertaining to the patient.

Letter writing skills and competence in language are immaterial.

Legibility is not a major problem as in an unstructured letter

Clarity is better with the structured format.

Headings remind the information to be included and thus improve the completeness of information.

Can be used for any patient irrespective of the system involved (cardiovascular/dermatology/psychiatry), type of referral (routine/urgent/emergency) and intention of the referral(opinion/advice/investigations/treatment or admission)

Minimal cost

Facilitates research and audit

Saves time of the recipient

Headings and structured format facilitate information retrieval.

This has been in use at the Family Medicine Clinic, Faculty of Medicine, University of Kelaniya which is a group practice and author's part time general practice in Sri Lanka for more than one year. Doctors who have used this letter have expressed positive views; “It saves time” “reminds information to be included” “looks professional”.