Target specialties with limited access for patients—they could be inundated with low-value referrals. These specialists also have intrinsic motivation to equip PCPs to treat these needs when they can.

For example, Brigham and Women’s Hospital’s dermatology department was receiving an overwhelming number of low-value referrals specifically for acne. So, they built a best practice advisory into their EHR. If a physician orders an acne referral, it asks whether the case is mild, moderate, or severe, with accompanying pictures. For mild and moderate cases, it offers a list of recommended therapies for the referring physician to consider ordering rather than making a referral. The referring physician can override the notification and send the referral anyway (or initiate treatment and send the referral), but the tool eliminates the low-value referral as the default option.

Brigham and Women’s conducted a prospective cohort study on this tool across 260 patients and 33 primary care sites from March 2017-2018. It found that the best practice advisory resulted in referral cancellation in 13.5% of cases and treatment initiation by the referring physician in 19.6% of cases.

The purpose of referral considerations is to empower referring physicians to make informed care planning decisions. Pseudonymed Rosemary Health created guiding questions to help PCPs prioritize high-risk skin cancer screenings. For dermatology patients with a prior history of skin cancer, Rosemary’s tool asks the referring physician three questions:

• What kind of cancer is it (Melanoma or non-Melanoma)?
• Is the patient immunosuppressed or otherwise has a history of a transplant?
• Are you suspicious of a lesion right now?

Leadership emphasizes that the point of the tool is not to give the PCP the “right answer” for treatment. Instead, it respects the autonomy of PCPs to treat higher-acuity cases and prioritizes for dermatologists which referrals are high-risk and necessary for urgent scheduling.

New York-based multispecialty group Crystal Run Healthcare includes representative physicians from primary care and all their specialties to determine clinical triage guidelines. They organize this work into two committee types: single-specialty committees for specialty-specific conditions and multi-specialty committees for cross-specialty conditions. These committees meet over time to iterate and increase exposure to new physicians. And leadership has noted that the process of facilitating collaboration and culture building between physicians is just as valuable as the guidelines themselves.