eRFA - Electronic Referral for Admission
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eRFA - Electronic Referral for Admission



Danette Holding, Project Manager eRFA & Karen Berry, Access Coordinator, from Hunter New England Health delivered this presentation at the 2012 Elective Surgery Redesign Conference. For more ...

Danette Holding, Project Manager eRFA & Karen Berry, Access Coordinator, from Hunter New England Health delivered this presentation at the 2012 Elective Surgery Redesign Conference. For more information about our wide range of medical and health events covering a broad range of industry issues, please visit



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eRFA - Electronic Referral for Admission eRFA - Electronic Referral for Admission Presentation Transcript

  • eRFA (electronic Request For Admission) Karen Berry District Access Coordinator Danette Holding Project Manager Melbourne 12 November 2012
  • John Hunter Hospital – Elective Surgery In Context • 27,000 procedural/ surgical cases pa, of which 37% (9,885) are elective. • Level 7 Tertiary Referral Service, Level III Trauma Centre • Approx 800 bed facility • Approx 17000 on waiting list (6000 at JHH), • Annually: 15,753 added to JHH list, 13,823 admitted for surgery, 2,144 removed for other reasons.
  • Planning For Admission
  • Handwritten RFAs • Over the full year, nearly 100% error rate!! • Average of 2.45 errors/ RFA – Consent with a large number of consent and planned procedure not matching. – Special OT requirements also strongly represented as missing data. • Illegible • Incomplete • Staff chasing specialist for clarification • Patient Questionnaire often incomplete
  • Admissions processes galore • Series of detailed cumbersome processes including: – When RFA required elsewhere, photocopies made and the copy left in Admissions (straight forward admission avg 8 movements) – Photocopies are annotated and then transcribed onto original, doubling the handling – iPM Waitlist comments transcribed to the paper RFA – Paper RFA must be unfiled, annotated and re-filed
  • Audit • Manual Auditing – over 1000 audit letters for each 150 day audit run every two weeks – returned audit letters must be filed with the RFA – each RFA retrieved, attached, annotated and re- filed – Phone calls generated from the auditing process
  • The Pre-Admission Process Limitations • Individual services wanting individual systems • Multiple versions of “RFA’s” • Multiple Pre-Admission Clinics • Resource intensive complex manual systems at capacity • Margins for error • The geographical lay out = risk of RFA “misadventure”! • Demand for review of “RFA document” by various services • Transfer between Dr’s and sites • Documentation
  • Unquantifiable risks • Inability to track: – How many RFAs were lost? – How many RFAs are never sent to Admissions? (Wait List Policy compliance) – Ensure the return of a postponed or cancelled patient’s RFA’s to Admissions from Operating Theatre. – Communication with sites/ AMOs
  • JHH Campus Perioperative Services Medical Specialty RFA’s Surgical Specialty RFA’s Cardiothoracic JHHCH RFA’s Admissions Audit queue Rheumatology Dermatology Respiratory Sleep Clinic Nuclear Medicine (different RFA) Cardiology (non procedural) Immunology General Medicine Endocrinology Nephrology Rehabilitation (RNC) Endoscopy Neurosurgery General Surgery Colorectal Surgery ENT Max Facs O&G Gynae Onc Vascular Vascular cath lab Gastroenterology (requring surgical intervention) Lung Cardiac Surgical (Sedation) Gastro (Sedation) Surgical (GA’s) JHH peri op Procedural Cardiology (including some cardiology pacemakers) Various referral sources on various types of RFA’s RFA sent for Procedural Cardiology team review Cardiology Periop triage assessment Procedural Cardiology ends here Admissions wait list queue If Periop assessment requested on RFA eRFA system will forward to the “other” periop queue (JHH Periop responsible for actioning to correct periop service) Pt awaits admission advice from Bed Manager who has copy of undated pt’s RFA in a folder Gastro (GA’s) Endoscopy NUM for Periop JHH/RNC Campus Perioperative Flow Chart Urology Elective Orthopaedics Opthalmology RNC Periop Cardiothoracic Periop Endoscopy NUM Periop JHHCH Periop Service JHH/RNC Periop RFA received via paper or electronically (EP) cardiology Periop triage assessment RFA sent for Procedural Cardiology team review Various referral sources on various types of RFA’s Procedural Cardiology (EP) (including some cardiology pacemakers)
  • Why an eRFA???
  • Developing A Solution • DOH offering $250,000. HNE funding the remainder • JHH Pilot site for eRFA (electronic Request For Admission) • Utilising existing Admissions and IT staff with a part time Project Manager • Main cost software, based on “adobe livecycle”, smaller extent, scanners and bar coders
  • Our Information Systems • Chief Information Officer • Clinical Systems Team – Over 300 applications, over 9000 individual computers, over 15000 users. – CAP (Clinical Access Portal) • eRFA developed by the Applications Development Team, launched from CAP
  • What else could be improved?
  • Streamlining Processes • Opportunity to Align Medical Admissions and elective surgical patients to a singular “Pre Admission” model • The traditional “Anaesthetic Clinics” (Perioperative Service) to sit within this process. • Pre-Admission processes guided by TCRA Policy (NSW MOH new Discharge Policy) 5 key elements for pre admission assessment.
  • Meeting KPI’s • Doctors KPI of ensuring RFA is submitted to Hospital within 3 working days of seeing the patient. • Manage workflows to improve compliance with requirement to add RFAs to the waiting list within 3 days of receipt of RFA • Ensuring matching documentation between iPM and the RFA • Introduction of mandatory fields ensures complete RFA documentation • Ensure patients requesting deferral are not added to the waiting list
  • • The eRFA Facilitates – Transfers of RFAs between facilities – Sharing of relevant clinical data – Management of short notice bookings – Discussion with pre-op services (both here and off site). Meeting KPI’s
  • Implementation Experience
  • Implementation Process • eRFA Working Party established, with representation from the key teams. • Regular forums to discuss progress, process challenges, prioritise work flow and feedback • Process of back scanning some 6000 RFA’s into system • Clinical engagement • Forums with Service and Clinician groups for feedback and identification of requirements/enhancements
  • eRFA Process Electronically submitted eRFA Paper RFA received and scanned in to eRFA system Admissions waitlist entry and audit process data entry into patient management system (iPM) updates eRFA system Electronic routing to various periop services Periop Periop Periop Periop +/- Perioperative Clinic assessment notes scanned into eRFA eRFA and perioperative notes available for review through CAP (token from rooms/home etc) “Batch print”from Admissions 2 work days prior to surgery forwarded to DOS unit Pt presents for surgery notes progress with pt eRFA Process Flow
  • Electronic Submissions • Since commencement of electronic submissions (April 2012) there have been 8986 RFA’s submitted • 976 of these have been electronically submitted (11%) • The remaining have been scanned into the eRFA system as a pdf document.
  • Benefits for Patients • Legibility and completeness of procedure, equipment, special requirements • RFA cannot be lost in the system risking a cancellation • RFA cannot be lost by a patient or ward for a staged or deferred procedure • Patient questionnaire form pre-filled from iPM and previous RFAs • Better prepared for procedure and discharge planning
  • Benefits for Clinicians • eRFA user friendly – Pre-filled data for procedures and patient details from iPM (including infection control alerts) • Surgical list within (CAP) Clinical Applications Portal • RFA available within (CAP • Ability to view previous RFA’s with accompanying perioperative documents.
  • Benefits to the Organisation • Congruence between paper and pt information systems • Improved quality in documentation • Admissions from “stretched” to increased capacity for throughput • Provision for mandatory check for procedure information and risks
  • Other Clinical Implications • Mandatory consent for blood transfusion and products on eRFA and infection control alerts (transcribed from iPM) • Critical Care referrals pre operatively • Tissue Bank consent • Discharge Planning (NSW TCRA Policy) – Case managers on wards for complex procedures/patients – Referrals to Allied Health
  • The Perioperative (service) process • Improvements to Triaging and requirement to review special instructions on the eRFA • Application within CAP that enables a GP referral (containing a health summary) to be reviewed at point of triage • Clerical efficiencies with negating the need for RFA retrieval, copying and tracking • RFA no longer required for clinics • Periop Service efficiencies with clinic notes being scanned into eRFA rather than summarised into patient information system (iPM) and visible in CAP
  • Challenges/ Risks
  • The Challenges • Managing the process change (size of project and stake holders, many directions with each challenge) • Clinician support (tech savvy) • Patient questionnaire and obtaining signature for consent (sig pad, printer issues in OP) • IT limitations, new software, CAP (actual electronic form) • IT Resources • Managing the scope of the initiative and prioritising • Maintaining Integrity of the Medical Record (Water Marks)
  • Challenges • RFA now singular pages (Pt ID and MRN) • Pharmacy • Children’s Hospital involvement (precursor to review of their own perioperative systems) • Managing the multiple systems through admissions during implementation phase • Maintaining the integrity of the medical record and patient safety • Momentum, enthusiasm and managing the implementation till embedded
  • Managing Admissions Processes through Implementation
  • Moving Forward • Tackling the challenges – Without complete roll out to ensure electronic submission the eRFA will be little more than an electronic wharehouse – Complete JHH Campus roll out, currently limited by IT resources – Roll out to Private Rooms – Roll out to the rest of HNELHD – Facility Representatives (Clinical and Administrative) – and change champions!
  • Thank you!