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Benefits and Lessons Learned - An e-Referrals Pilot in the Waikato


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Paul Docherty
Waikato District Health Board
(P32, 17/10/08, Experience stream, 10.50am)

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Benefits and Lessons Learned - An e-Referrals Pilot in the Waikato

  1. 1. Benefits and Lessons Learned: An e-Referrals Pilot in the Waikato HINZ Conference October 2008 Paul Docherty, Project Manager Waikato District Health Board
  2. 2. Outline <ul><li>Waikato DHB Region </li></ul><ul><li>Definitions </li></ul><ul><li>The Problem </li></ul><ul><li>Pilot Project (Scope) </li></ul><ul><li>Solution Outline </li></ul><ul><li>Benefits & Lessons Learned </li></ul><ul><li>- GP, Referral Centre, Triage, Other </li></ul><ul><li>What Next </li></ul><ul><li>Acknowledgements </li></ul><ul><li>Questions (time permitting) </li></ul>
  3. 3. <ul><li>Waikato DHB </li></ul><ul><li>5 Hospitals </li></ul><ul><li>2 Continuing Care & Maternity Facilities </li></ul><ul><li>21 Community Bases </li></ul><ul><li>Primary Care </li></ul><ul><li>250 + GPs, based at </li></ul><ul><li>nearly 100 Practices </li></ul><ul><li>Coverage </li></ul><ul><li>340,000 people </li></ul><ul><li>Tertiary hospital for 780,000 people (Midland) </li></ul>Waikato District Health Board
  4. 4. Definitions <ul><li>Referral: </li></ul><ul><li>A request for service from a service provider to another service provider on behalf of a patient. . . With the intent of a transfer of care, in part or in whole [HISAC] </li></ul><ul><li>Register: </li></ul><ul><li>The process of collecting required administrative and clinical information for efficient processing of the referral request, for reporting and management of the referral. </li></ul><ul><li>Triage: </li></ul><ul><li>The process of assessing the referral to determine the appropriate course of action for the request </li></ul>
  5. 5. The Problem <ul><li>Waikato DHB’s Referral Coordination Centre </li></ul><ul><li>Covers Elective Outpatient Clinic Referrals </li></ul><ul><li>Receives between 1,000 & 1,700 referrals per week (variance is mostly seasonal) </li></ul><ul><li>Waikato DHB’s Regional Referral Centre </li></ul><ul><li>Covers Community Service Referrals (inc. District Nursing, Community Physio, OT & Social Work) </li></ul><ul><li>Receives 600 to 700 referrals per week </li></ul>
  6. 6. Simplified Referral Process Register Initiate & Transmit Triage General Practice Primary Care (other) Internal (Waikato DHB) Other DHB RCC – Outpatient RRC – Community Mental Health ED – Acute Specialties / Specialist Team Leaders Nurse Specialists Pilot Scope: Initiation from General Practice Outpatient Clinic Referrals
  7. 7. Referral Receipt Pilot Project (R2P2) <ul><li>Scope: </li></ul><ul><li>5 GP practices (mix of big, small, rural, & urban sites) </li></ul><ul><li>Generic referral template (one size fits all) </li></ul><ul><li>GP Practice to Referral Coordination Centre (Outpatient clinic referrals) </li></ul><ul><li>6 months ( November 2007 to May 2008) </li></ul><ul><li>MedTech32 to MedTech32 [Practice Mgmt System] </li></ul><ul><li>Uses HealthDocs [XML message type] </li></ul>
  8. 8. The Solution Referral Message Message-ACK Status Message (Manual from MedTech32)
  9. 9. Solution Outline <ul><li>In the Practice: </li></ul><ul><li>Referrer opens the template (Outbox Document) </li></ul><ul><li>The template auto-populates patient demographics & some clinical information </li></ul><ul><li>Referrer completes the remainder of the referral template </li></ul><ul><li>Referrer transmits the referral electronically </li></ul><ul><li>In the Referral Centre: </li></ul><ul><li>Message received by MedTech32 </li></ul><ul><li>Clerical staff register the patient (in MedTech32) </li></ul><ul><li>Referral is printed for registration & triage </li></ul><ul><li>An acknowledgement (Receipt) message is sent back to the referrer – Using a different Outbox Document </li></ul>
  10. 10. Benefits - Referrer <ul><li>For the Referrer (GP): </li></ul><ul><li>Referral more likely to be completed during the consultation time [reduces referrer admin time] </li></ul><ul><li>Referrer is less likely to be contacted to provide additional information [reduces referrer admin time] </li></ul><ul><li>Due to auto-completion of patient and clinical details into the template – Referrer may only need to provide 1 – 2 paragraphs of additional clinical information </li></ul><ul><li>Referrer has certainty that the referral has been received by the Referral Centre </li></ul><ul><li>The referrer receives an Acknowledgement (Status) Message, which advises expected triage timeframes, integrated within their Practice Management System (within 1 working day). </li></ul>
  11. 11. Benefits - Practice <ul><li>For the Practice: </li></ul><ul><li>Reduction in Transcription (Dictation & Typing) </li></ul><ul><li>Due to: Referrer is more likely to type the 1 – 2 paragraphs of additional clinical information themselves </li></ul><ul><li>Reduction in Paper-Based Referral Handling </li></ul><ul><li>The referral is not sent by fax or mail and no handling is required by clerical support staff </li></ul><ul><li>Reduction in Requests for Clarification from the Referral Centre </li></ul><ul><li>Auto-population of patient demographics means the referral is more likely to be complete (and therefore clarification is not required) </li></ul>
  12. 12. Benefits – Referral Centre <ul><li>For the Referral Centre: </li></ul><ul><li>Reduction in Duplicate Referrals </li></ul><ul><li>Referrer has certainty that the referral has arrived, and has a timeframe for Triage – less likely to send the same referral again </li></ul><ul><li>Reduction in Requests for Clarification from the Referral Centre </li></ul><ul><li>Auto-population of patient demographics means the referral is more likely to be complete (and therefore clarification is not required) </li></ul><ul><li>No Net increase in Referral Registration Time </li></ul><ul><li>Requirement for additional processing of an electronic referral, was offset by time savings above – 20 min per referral registration time was maintained. </li></ul>
  13. 13. Benefits – Triage <ul><li>For the Triage Clinician: </li></ul><ul><li>Reduction in Requests for Clarification to Referrer for Missing Clinical Information </li></ul><ul><li>Auto-population of some clinical information means the referral is more likely to be clinically complete </li></ul><ul><li>Standard Format / Layout Assists Triage </li></ul><ul><li>Logical standardised structure of the template assists Triage. This may also have reduced need for clarification </li></ul><ul><li>Referral is Readable </li></ul><ul><li>Easier to read typed than handwritten. Easier to read than typed then faxed. This may also have reduced the need for clarification. </li></ul><ul><li>Referrer training for the Pilot may also have improved referral readability </li></ul>
  14. 14. Benefits – Patient <ul><li>For the Patient: </li></ul><ul><li>Increased Certainty of Send </li></ul><ul><li>Patient was more likely to see the referral initiated (if not completed) while they were still present in the consultation (with their GP). </li></ul><ul><li>Increased Certainty of Receipt </li></ul><ul><li>Practice able to provide timeframes for turnaround of their referral. Practice also able to confirm that the referral had been received by Waikato DHB </li></ul><ul><li>Accuracy of Triage </li></ul><ul><li>Hearsay evidence suggests that specialists decisions were better informed as a result of referral being less likely to be incomplete. </li></ul>
  15. 15. Benefits - Other <ul><li>Collaboration </li></ul><ul><li>IT / IS Collaboration between Waikato DHB, Waikato Primary Health & Pinnacle worked very effectively to achieve common objective </li></ul><ul><li>Relationships </li></ul><ul><li>Relationships improved between Waikato DHB and GP practices overall; practices could see the DHB delivering benefit for them </li></ul><ul><li>‘ Training effect’ improved understanding of what happened to their referrals once they left their practices. The process at the Waikato DHB was better understood by the referrers </li></ul><ul><li>Benefit Summary </li></ul><ul><li>There was benefit for all participants of the process – particularly for the referrer </li></ul>
  16. 16. Lessons Learned <ul><li>Solution Problems </li></ul><ul><li>Not Scalable </li></ul><ul><li>Solution required manual install of the template in every practice, every time an update to the template occurred. OK for 5 Practices – not for 100 </li></ul><ul><li>Not Extendable </li></ul><ul><li>Solution would not extend to service / specialty specific templates (desired by Triage specialists to further improve information provided by referrers ) </li></ul><ul><li>Solution is Still in Place – Unable to Turn Off </li></ul><ul><li>Pilot practices were very clear and insistent that the ‘pilot’ solution not be turned off. </li></ul>
  17. 17. Lessons Learned <ul><li>Clearer Understanding of Stakeholder Requirements </li></ul><ul><li>GP </li></ul><ul><li>GP wants to retain a copy of the referral document (in their own system). </li></ul><ul><li>GP wants certainty (Status Message) – which also provides proof of discharge of their ‘Duty of Care’ responsibility </li></ul><ul><li>Specialists / Triage Clinicians </li></ul><ul><li>Want Service / Specialty specific referral templates </li></ul><ul><li>Want automation of referral Work Flow </li></ul><ul><li>No Longer Theoretical Benefit – Benefit has been Proven </li></ul><ul><li>The Pilot has unlocked the ‘purse strings’ </li></ul><ul><li>Proven that the benefit is real, bankable & sizeable no longer theoretical & not intangible </li></ul>
  18. 18. What Next? <ul><li>Alternative Initiation Mechanism </li></ul><ul><li>Waikato DHB is currently working with Waikato Primary Health & Pinnacle on an alternative Internet Based Referral Template (Based on BPAC – bestpractice) – Hope to commence pilot before the end of 2008. </li></ul><ul><li>Registration & Triage </li></ul><ul><li>Planning Scoping and Analysis Project has been initiated to analyse Registration and Triage Process – with the objective of specifying a client to support these processes & be able to specify requirements for specialty specific referral templates. </li></ul><ul><li>Regional & National Engagement </li></ul><ul><li>Waikato DHB is keen to contribute to Action Zone 8 (eReferrals) of the Health Information Strategy for New Zealand (HIS-NZ 2005) </li></ul>
  19. 19. Acknowledgements <ul><li>5 Pilot GP Practices </li></ul><ul><li>Thames Medical Centre, Health Te Aroha, Te Awamutu Medical Centre, Fairfield Medical Centre, Hamilton East Medical Centre – without whom the pilot would not have been possible. </li></ul><ul><li>Waikato Primary Health & Pinnacle </li></ul><ul><li>Active collaborators in delivering the pilot – without whom the pilot would never have been initiated </li></ul><ul><li>Vendors </li></ul><ul><li>MedTech Ltd, HealthLink – who provided advice and rapid assistance in problem resolution </li></ul><ul><li>Referral Coordination Centre Staff </li></ul><ul><li>Clerical staff took on the additional duties with good cheer – before it was determined whether the solution had neutral impact. </li></ul>
  20. 20. Questions? <ul><li>Additional Information: </li></ul><ul><li>Copies of major project products (Business Case, Specs, Training Documentation, External Evaluation, Template) can be requested by contacting the Paul Docherty c/o Waikato District Health Board </li></ul>