Impact of Implementation of Electronically Transmitted Referrals on Pediatric Subspecialty Visit Attendance


Ray KN, Drnach M, Mehrotra A, Suresh S, and Docimo SG. 2018. “Impact of Implementation of Electronically Transmitted Referrals on Pediatric Subspecialty Visit Attendance.” Acad Pediatr, 18, 4, Pp. 409-417.



One barrier to timely access to outpatient pediatric subspecialty care is the complexity of scheduling processes. We evaluated the impact of implementing electronically transmitted referrals on subspecialty visit attendance.


Through collaboration with stakeholders, an electronically transmitted referral order system was designed, piloted, and implemented in 15 general pediatrics practices, with 24 additional practices serving as controls. We used statistical process control methods and difference-in-differences analysis to examine visits attended, appointments scheduled, appointment nonattendance, and referral volume. Electronically transmitted referrals then were expanded to all 39 practices. We surveyed referring pediatricians at all practices before and after implementation.


From April 2015 through September 2016 there were 33,485 referral orders across all practices (7770 before the pilot, 11,776 during the pilot, 13,939 after full implementation). At pilot practices, there was a significant and sustained improvement in subspecialty visits attended within 4 weeks of referral (10.9% to 20.0%; P < .001). Relative to control practices, pilot practices experienced an 8.6% improvement (P = .001). After implementation at control practices, rates of visits attended also improved but to a smaller degree: 11.8% to 14.7% (P < .001). In survey responses, referring pediatricians noted improved scheduling processes but had continued concerns with appointment availability and referral tracking.


While electronically transmitted referrals improved visit attendance after pediatric subspecialty referral, the sizable percentage of children without attended visits, the muted effect at control practices, and pediatrician survey responses indicate that additional work is needed to address barriers to pediatric subspecialty care.

Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Last updated on 05/22/2019