E-referrals.. Just do it!

Overview: Our pre-electronic era Where we are now at Value of the generic form Recommendations

Problems from a GP perspective Mailing out of date compared to how they communicate with other external agencies Lack of trust in the hospital processes →faxing and mailing No clear guidelines on what information to include Multiple possible destinations for the same referral type Delayed and dislocated notification of the referral processing stages to the referrer

Problems from a hospital perspective No way to track a referral from primary care until entered Referrals being sent to specialists, to services and to Central Referrals Lost referrals: how many, where did it happen? Duplicate referrals (faxing and mailing)

And yet more problems… Faxing errors Multiple phone calls to services to check up on referrals 100% variation in referral processing by the services (non standard work→ errors hidden) Disconnect across the referral processing workflow (errors not being feedback to source)

What about the content? (audit MOPC referrals 2009) 150 GPs – at least 50 different formats Inconsistent inclusion of relevant clinical information (medications/problem lists) 14% lacked of clarity of the question being asked by the referrer 33% lacked results that would influence prioritisation 14% used wizard “cut and paste” to include more than 5 consultations

Extensive use of “wizard” 75%: no clear reason for referral 50%: did not include relevant results %: of the C+P consultations contain irrelevant material information dumping Risk to both patient and recipient

Summary of audit findings The majority of referrals contain the appropriate information BUT presentation of this information inconsistent and not easily accessible to the recipient.

Main problems/risks to address GP: Replace paper with an electronic process Hospital: 1.Faxing 2.Cut and paste technique 3.Processes applied to the referral 4.Presentation /accessibility of information

Going electronic 2008 MOH call for submissions for pilots to improve access to diagnostic services NPIGG support to convert paper to electronic Healthlink contracted to produce 3 e-forms based on Hutt DHB e forms in use March 2009 Release of e-referral platform consisting of a colorectal, breast and generic forms

Where are we up to? Outpatient referrals only 5 customised forms, all other referrals via generic template Electronic processing at Central Referrals Office Standardised referral processing across services Printing of referral at service level beginning

After 6 months we thought… Gains in referral quality where to be found with customisation The generic form had little to offer other than providing an interim complete platform

The generic form What has it given us?

Overall uptake – 92% (Oct 2010) of all OPC referrals electronic

GP benefits Faster for GP Anecdotal reports of referral done frequently at time of consultation Reduction in after-hours work load 95 % completed Monday-Friday 75% of these between 8am and 5pm “they have revolutionised my referral work ” Dr A Miller Provided a standard work flow

More GP benefits Improved security: –real time acknowledgement of receipt –No referral losses (in the e-system) Improved clarity as to what service to make the referral to (single point of entry) No confusion as to where to send the referral

And more….. Decision support available:

Hospital benefits from the generic e-form Eliminated faxed referrals to OPC Improved security Provided ability to audit work flow Improved demographic data inclusion No more inappropriate cut and paste Standardised presentation improved accessibility of information to ALL groups faster and easier to process

Hospital benefits beyond the forms Prompted a review of all processes “Single point of entry” for all referrals via central referrals Standard work flow for processing all referrals across all services (error proofing rather than error finding) Linked staff across services in the same work flow Introduced concept of errors going back to source Prompted a review of how we manage referrals to out peripheral hospitals (equity across Northland)

An un-intended spin off.. Due to the standard presentation, quality issues exposed. stimulated interest of the hospital clinicians in referral quality Unmasked errors: –Problem list: 56% error rate –Medication list: 46% error rate –of these 78% were clinically significant

Patient benefits? Referral done closer to the decision made to refer Clinical referral information: – an initial drop, now neutral We don’t loose their referral

Consistent clinical information: positive influence on prioritisation but even bigger benefit at time of assessment. Medication list Problem list Paper referral55% Generic e-referral 100%

Summary

Electronic referrals out perform paper ones The generic form: enables rapid deployment of a electronic system offers GPs a consistent, faster and more secure work flow that is easily adopted Has benefits to all hospital staff and patients Minimal change with significant gain Big bang for your buck

Asking GPs to make yet more change……

Successful customisation: what does it take? Time: To define the problem (why are we attempting this) To quantify the size of the problem To understand the patient flow the form will support To review and optimise the work flow the referral will enter Money to support: GP/service collaboration in designing The form to be “built” by the IT vendor To engage with the users as to “why” at rollout Evaluation post roll out with evolution (continuous improvement projects) Skill: it’s not as easy to produce a good form as you might think

Customised forms can add value but… Referral security and information integrity are higher priorities to address. They need a reliable electronic platform on which they can be placed, get this sorted first.

Recommendations 1. Introduce a generic platform “to the front door” 2. Address problems at the GPs end while addressing hospital processes 3.Consider customisation only once we have a robust platform. Undertake as part of a service review process that includes GPs

Our future priorities

Referral security: Incremental movement towards a full end to end solution Referral quality and function: Further evaluation of our current forms Improving feedback from all users Work with GPs/PHO to improve data quality from PMS Add acute referrals to the platform Customisation only if a problem big enough is identified as part of a service redesign process

Acute referrals audit (10/2010) Service being referred to often not clear Name of accepting clinician rarely present 45% had no medication list 45% had no patient problem list Referral not present prior to patient presenting

Please lets stop re-inventing the wheel…. Continuous collaborative improvement

For any further information: Wendy Carey: Surgical services OP manger Peter Brown: elective services project manager Glenys Wynyard: Central referrals office manager