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E-referrals - Just do it!
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E-referrals - Just do it!

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Dianne Davis …

Dianne Davis
Northland District Health Board
(3/11/10, Civic 2, 2.30)


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  • 1. E-referrals.. Just do it!
  • 2. Overview:
    • Background
    • Where we are now at
    • Analysis of customisation
    • Value of the generic form
    • Recommendations
  • 3. Our pre – electronic era
    • 150 GPs - 50 letter formats: paper, labelling
    • Inconsistent inclusion of clinical information
    • Delayed notification of the referral processing stages to the referrer
    • Lost referrals: how many, where did it happen?
    • Lack of trust from GPs;
      • duplication of referrals (faxing and mailing)
      • multiple phone calls
    • 100% variation in referral processing by services
    • Disconnect between departments
  • 4. 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
  • 5. 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
  • 6.  
  • 7.  
  • 8.  
  • 9.  
  • 10.  
  • 11.  
  • 12. Where are we up to?
    • Outpatient referrals only
    • 5 customised forms, all other referrals via generic template
    • Electronic processing at Central Referrals Office (central processing for ALL referrals)
    • Standardised referral processing across services
    • Printing of referral at service level
  • 13. Outcomes of our customisation…
  • 14. The Colorectal form
  • 15. Process
    • Understanding of referral types
    • Streamlined service to improve patient flow
    • Research to establish evidence base for referral content
    • Collaborative design of form - 1 °/2° care and IT vendor
    • “ road show” by lead clinician to engage users, what and why
  • 16. Benefits to GPs
    • Speed of use: 44% a lot faster
    • 44% somewhat faster
    • 12% same
    • Guidance: 62.5% very helpful
    • 37.5% somewhat helpful
    • 70% rated the usability of the form 8/10 or better
    • Uptake: overall e-referrals 60-70%
    • Colorectal form 85%
  • 17. Benefits to specialist
    • 30% reduction in triage time
    • Improved a ccuracy of triage:
      • 100% of low risk patients required no 2 ° care intervention (6 month reviewed no further presentations
      • 68% of cancer cases rated urgent vs. 50% pre e-referral
  • 18. Benefits to patients
    • Accurate prioritisation means right queue
    • But…no change in time frame from referral to diagnosis
    • ( function of inconsistent application of processes and capacity constraints)
  • 19. Why has it worked well?
    • Clearly defined and clinically important problem
    • Full service review
    • Evidence based form content
    • Collaborative form design
    • High engagement and education from specialist for GPs
    • BUT = TIME and MONEY
    • (and there’s improvements still be made)
  • 20. The breast form
  • 21. Process
    • Un-used paper referral form used as clinical starting point
    • Meeting with triage staff and GPL, design based on Colorectal form
    • Email communication with the IT vendor
    • Released after letter sent to all GPs about the service changes and the new form
  • 22. But….
    • Not meeting needs of either GPs or service
      • Did not support all referrals types
      • Information supplied impeded prioritisation
    • Version 2 developed after an informal meeting with a small GP group and triage staff
  • 23. How is it going (GPs)?
    • Slower to generate for some referral types than the paper system
    • “ a bit clunky” to use, doesn’t reflect the normal GP work flows
    • “ It’s OK”
  • 24. How is it going (service)?
    • Conflicting tick box and free text information
    • -> Slower to prioritise
    • Reduction in free text clinical information
    • -> loss of information
    • Clinical information clearer in paper version but supporting information (medication and problem lists) better.
  • 25. Why it didn’t work well
    • Problems with paper referrals not clearly defined
    • Patient referral types not defined
    • Inadequate collaborative design process
    • Inadequate GP engagement and education
    • Poor process = poor gains
    • Should we have done it?
  • 26. The generic form
    • What has it given us?
  • 27. Overall uptake – 92% (Oct 2010) of all OPC referrals electronic 0 500 1000 1500 2000 2500 March April May June July August September October November December January February March April May June July August September 2009 2010 e-referrals total referrals
  • 28. 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
  • 29. More GP benefits
    • Improved security:
      • real time acknowledgement of receipt
      • No referral losses
    • Decision support available:
  • 30. Hospital benefits
    • Eliminated faxed referrals to OPC
    • Improved security
    • Provided ability to audit
    • Improved demographic data inclusion
    • Standardised presentation
      • improved accessibility of information to ALL groups
      • faster and easier to process
  • 31. Patient benefits?
    • Clinical referral information:
      • an initial drop , now neutral
    • More consistent clinical information:
    Medication list Problem list Paper referral 55% 55% Generic e-referral 100% 100%
  • 32. An un-intended spin off..
    • Standard presentation stimulated hospital clinicians interest referral quality and data integrity, prompted us to quantify
    • Unmasked errors:
      • Problem list: 56% error rate
      • Medication list: 46% error rate
        • of these 78% were clinically significant
  • 33. Summary
  • 34.
    • 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
  • 35. Asking GPs to make yet more change……
  • 36. Customised forms can add value but…..
    • Referral security and information integrity are higher priorities to address.
    • Only consider
      • Once there is a clearly identified need
      • After the patient referral pathways are clearly defined
      • By those that do the work
  • 37. Customised forms…
      • Require good clinical engagement to get buy in and good use:
      • what problem are we attempting to resolve
      • what is the process to evolve them
    • Are continuous improvement projects
      • Are very resource hungry
  • 38. Recommendations
    • Introduce a generic platform “to the front door”
    • Address problems at the GPs end while addressing hospital processes
    • Consider customisation only once we have a robust platform.
    • Undertake as part of a service review process that includes GPs
  • 39. Our future priorities
  • 40.
    • Referral security:
    • Incremental movement towards a full end to end solution
    • Referral quality:
    • Further evaluation of our current forms including feedback from all users
    • Work with GPs/PHO to improve data quality from PMS
    • Add acute referrals to the platform
    • Customisation only if a need is identified as part of a service redesign process
  • 41.
    • What about DHB collaboration?
  • 42. Acknowledgements
    • NPIGG
    • Hutt DHB
    • Mr Mark Sanders General Surgeon
    • Healthlink
    • The GPs of Northland
    • HINZ
    • Further information:
    • [email_address]