Not long ago, I had a patient with some difficult pathology, so I referred her to a surgeon at a higher level of care.

Six weeks later, she’s sitting in my exam room again, asking me what he found.

I went back and I scoured her record. I had nothing. Not a summary, not a fax. Not one line in the chart.

I sent her out with a real question, and the answer was out there somewhere. Just not with me.

So, I did what a lot of us do in that moment. I smiled. I explained that there can be, you know, delays in getting information, and I assured her that I would check on it. I immediately sent a video shot of her information with an explanation to my team on ClinicianCore, with plans to bring the patient back next week. My team would get all the information for me, and then I’d see the patient back.

I then sent a text to the surgeon—unfortunately, he’s not on ClinicianCore yet—to try and sort it all out.

Welcome back to The Connected Practice. I’m Dr. Kevin Halow, surgeon, veteran, co-founder, and Chief Medical Officer of ClinicianCore.

This podcast is about the routine that should not be. Specifically, the difficulty in getting an answer in medicine. This case—a true case report—is not a one-off. It’s a routine event. If you’ve been in practice for more than a year, you already know exactly the communication breakdown that I am describing.

It does not have to be this way.

Do you know why this scenario is so familiar? Want to hazard a guess? Well, turns out that you have a less than 50% chance that you’ll get the information you need back when the patient returns to see you. In fact, on average, 65% of referrals come back without documented answers from the referring physician.

Now, it’s not to say that 65% get lost in the mail, but rather 65% of the time, the loop just doesn’t close, and the information isn’t there.

I want to be precise about what that means, because it’s easy to hear that number and think, “Ah, it’s operational inefficiency.” You know, the faxes stopped working or the email went down. That does happen. However, that’s not the real story here.

The real story is this: you’re the one who has to decide what happens next for that patient. Adjust the medication, decide on a surgery, or maybe order a follow-up test. Tell them it’s fine, tell them it’s not, make a plan for care. Yet, in almost two out of three referrals, you are making that call without the complete information from what that specialist actually found.

Okay, let’s reframe it a bit. There are downstream consequences to events like this. It’s referred to as referral leakage.

Patient becomes dissatisfied, so the practice loses the patient. Loses the follow-up visit, loses the billing, loses the revenue. That is all true. However, those are second-order events. The first-order effect is that you are practicing with a gap in the record.

You send a patient out because they need a higher level of care, and with that higher level comes additional information. When they return, that information needs to come with the patient. If that information does not come back, you have not just lost a data point, you have lost the entire reason you made the referral.

Okay, think for a moment. The true meaning of that referral. It’s not a handoff; it’s a process. And you’re still responsible for the patient. You have a specific question, and you need a specific answer to that question. You need to close the loop.

When the loop doesn’t close, that’s not a scheduling failure. That’s a break in the chain of custody of a person’s care.

So, where does the break in this chain occur?

Well, it’s almost never at the moment of decision. The specialist doesn’t decide not to tell me. It’s a break in the system. The referral goes out by fax or by portal that doesn’t talk to my EHR. The patient is seen, and the consult note gets written into the specialist’s system. Those systems do not communicate. Ironically, nobody owns the step of routing that note back to me, because neither system treats sending that answer back as a task with an owner and a deadline. It’s treated like a courtesy, not a workflow.

And when there’s no owner and no deadline, that note just sits. Or, it goes to a fax queue that no one checks. Maybe it’s filed on their end and no one flags it for transmission at all. Multiply that across every referral every physician sends, and 65% stops being surprising. It’s what you’d expect from a process that no physician ever designed.

Allow me to make this concrete. Patients come back to me before the specialist’s note ever arrives. I have two choices: I can chase it down myself, calling the specialist’s office—which takes time I don’t have between patients—or, I can make a decision with partial information, and I tell myself it’s probably fine. Sometimes, you can make do. But is it really fine? Is it okay? I mean, after all, it’s really not the standard to which you were trained.

Every physician listening to this knows exactly the feeling I’m describing. That low hum of uncertainty when you’re documenting a plan, and you know there’s a consult note out there somewhere, and that might change your plan. That’s the true cost. As a physician, you’re trying to make the next clinical call with a hole in the picture, and what is missing could be really important.

And in reality, that hole should not be there. As a physician, you need to see the entire picture. That’s the care the patient has come to expect from you, right?

Okay, what’s the fix?

Well, fixing this isn’t about asking a specialist to care more. They do care. It’s not a lack of caring problem. It’s about making the return trip of a referral a tracked, owned step, the same way we treat the outbound referral itself.

That means the referral has a status, not just a send date. Sent, received, consult complete, note returned, reviewed by referring physician. If any of those stalls, someone should see it stall before the patient is back in your exam room asking you questions that you can’t fully answer.

That is the whole idea behind ClinicianCore’s concept of Unified Clinical Communication. One thread that follows the referral from the moment you send it to the moment you have actually read what came back. If the loop doesn’t close, the system tells you it didn’t close. There’s no searching anymore, there’s not another portal to check. You stop finding out by accident six weeks later, when the patient is sitting in front of you, that the information is not back yet.

I did not get into medicine to manage fax queues. None of us did. But right now, closing the loop on a referral is treated as optional, and it’s costing us the one thing a referral is supposed to protect, which is continuity of patient care.

If you want to see what a closed referral loop actually looks like in practice, I broke it down in the companion article. You can follow the link from this podcast. Take a look. Then think about how many referrals you’re still chasing down yourself every time you see clinic.

Okay, that’s it for today’s podcast. Don’t forget to check us out at clinicioncore.com. While you’re there, sign up for our waitlist for our upcoming September release. You can also check out our many podcasts, webinars, blogs, and whitepapers. Finally, you can follow us on LinkedIn, Facebook, Instagram, Spotify, and Reddit.

I’m Dr. Kevin Halow, co-founder and Chief Medical Officer of ClinicianCore. Let’s make closing that referral loop an expected part of your practice.

Thanks for listening.