INTEGRATION OF REFERRAL INFORMATION AND PATIENT FLOWS: THE ROLE OF REFERRAL MANAGEMENT IN TAYSIDE Linda Fox/Rebecca Locke

A History Lesson Implementation of locally developed system Electronic Referral Service (ERS) for electronic referrals to all provider units across Tayside excluding Community Services –Live within 7 pilot practices in May 2001 Receipt by Medical Record Departments across Tayside & printed off SIGN guideline compatibility for all specialties 5 protocol referrals were developed: General psychiatry (for 1 CMHT) General Surgery – Breast clinic Menorrhagia Pain Clinic Vascular Surgery – carotid endarerectomy

Moving on to a Referral Management System June Dermatology participated in a pilot enabling clinicians to electronically screen referrals. Clinicians screen referrals at source with the following options: Booking clinic requests Cancelling referrals Redirecting referrals to other specialties/locations Messages are sent electronically back to the GP practice via ERS indicating any updates.

Impact of ERS/RMS within NHS Tayside Reduction in the Patient’s Timeline Extended Referral Management capacity Robust information to Medical Records from Clinicians screening Currently 84% of referrals in e-format 4,519,177 current running total 84% of all referrals are electronically managed on line either in one or all locations across Tayside

What Happened Next and When? Introduction/migration of SCI-Gateway Pilot commenced 5 th November 2007 completed May 2008 Over 5377 referrals processed during pilot In addition referrals being received within Medical Records from GP practices outwith Tayside Full training and roll-out to all Tayside practices following successful pilot conclusion and review.

Referral Management

Select the location, specialty, protocol and clinician

A digital photograph of a lesion is attach to the referral…..

…and the referral is sent through the Gateway

…and arrives in RMS

The medical staff on call from screening in dermatology receive the referral…

…and screen it

Upon screening, redirect referral to Plastics – Skin Lesion ….

Gateway is updated accordingly ….

and referral now received by Plastics

The patient is booked into a clinic and the status of the referral is raised to urgent

The new status of the referral is sent back to the Gateway

In RMS the referral is printed and the booking confirmed …

…and the final status is sent back to the Gateway

Locally Agreed Referral Pathways Tayside Colorectal Service – protocol based referral introduced pan-Tayside. Tayside Skin Tumour Service – collaborative working with 3 disciplines (Dermatology, Plastics Surgery & Oral and Maxillofacial with links to Ophthalmology) – Joint screening with digital photographs, introduced across Tayside, into agreed management algorithms. Surgical Vascular Services – referral management pathway to include vascular laboratory testing. First Seizure Service – protocol developed and includes mandatory information to risk manage the patient.

Colorectal Protocol Based Referral storyboard – Key Information

Colorectal Protocol Based Referral storyboard – Clinical Information………

SCI-Gateway referral Compliant with National Standards National ‘HEAT’ status updates electronically passing back to SCI-Gateway from RMS for all patient referrals. Tayside protocol modification to indicate – ‘Urgent Suspected Cancer’ in accordance with 62 and 31 day Cancer pathways. Facility to record UK Veteran status to allow appropriate management of patients.

RMS Development Generic screening options include ‘Any outpatient clinic, redirection, up/downgrade, cancellation (clinical messaging back to General Practice), flag-to (specific clinician or service). Specialty generic and/or clinician alert for flagged referrals. Screening/Triage Clinician directed RMS ‘options’ E.g., Orthopaedics – Physiotherapy. E,g., Medicine for the Elderly – Falls Clinic.

The Future Complete alignment of referrals and referral management by all specialties with integration with PAS, and delegated appointment booking. Clinical Directory to be developed and introduced containing referral pathways and referral guidance. Introduction of electronic test requesting and appointing. The ability to attach documentation to the referral in secondary care by April 2010 – developed specifically for the Pain services to allow patient questionnaires to be electronically incorporated with the original referral. Clinical messaging back to General Practice from RMS through the EDT server into Docman. More Protocol Based Referrals to be developed following consultation with General Practice and Secondary Care

The future continued…… SCI-Gateway referral by GDP and referral screening by Hospital Dental Services. Inter-Hospital Usage of SCI Gateway for tertiary referrals. Development and adoption by Community Services of SCI- Gateway and RMS (referral screening) e.g. Dietitians, Physiotherapy, Speech and Language therapy. Inclusion of Mental Health Services in PBR development and referral screening.

Comments by Clinicians on-line screening Mr Amar Jain, Consultant Orthopaedic Surgeon, (specialises in Orthopaedic Foot referrals). “I must admit I was a bit sceptical of whole system as I am a technophobe and computer illiterate. But I am pleasantly surprised how easy it was to get on it. After a few teething problems for me now it is functioning very well. Your and your colleagues’ support has been very valuable for me. It has been very useful in screening Foot referrals. This has made the whole admin of referrals easy and faster. Even I can recommend to all without hesitation.”

Dr James Cotton, Consultant Gastroenterologist. “Prior to the implementation of RMS my colleagues and I had some concerns if it would influence the way we worked on a day to day basis of managing referrals: How we would manage personal referrals and how would we screen referrals. We have seen benefits in managing referrals since implementation of RMS. We can screen anywhere on our intranet, it is easier to redirect referrals and to cancel them with feedback for the GP. Referral rarely get lost!” “From an audit point of view we can get better data regarding our referral patterns, and management. It did required a change in how we work and work as a team, but we have seen the time to screen drop to a mean time of 1 day.” “Future developments into integrating the system with other hospital systems and results management would be welcome, which I believe is currently being looked into.”

Some Challenges… Customisation for individual specialties is labour intensive and development requires considerable support. Support Team needs to be fully integrated, good communication in place to effect change. In Tayside we still have a mixed economy – electronic and paper based referrals and referral management. Still new patient pathway development reliant on paper faxed route for referral/management. Expectations raised, ‘immediate development’ now requested. Dealing with the ‘less keen’.

Doing things differently? Reprioritise to HEAT – ref 2005 Roll out of two programmes at the same time – SCI-Gateway and RMS. Earlier link of RMS with PAS appointment booking. Integration of patient demographics and administration data with test requesting from RMS. Communication strategy.

Questions & (Hopefully) Answers