E-referrals - Just do it!


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

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E-referrals - Just do it!

  1. 1. E-referrals.. Just do it!
  2. 2. Overview: <ul><li>Background </li></ul><ul><li>Where we are now at </li></ul><ul><li>Analysis of customisation </li></ul><ul><li>Value of the generic form </li></ul><ul><li>Recommendations </li></ul>
  3. 3. Our pre – electronic era <ul><li>150 GPs - 50 letter formats: paper, labelling </li></ul><ul><li>Inconsistent inclusion of clinical information </li></ul><ul><li>Delayed notification of the referral processing stages to the referrer </li></ul><ul><li>Lost referrals: how many, where did it happen? </li></ul><ul><li>Lack of trust from GPs; </li></ul><ul><ul><li>duplication of referrals (faxing and mailing) </li></ul></ul><ul><ul><li>multiple phone calls </li></ul></ul><ul><li>100% variation in referral processing by services </li></ul><ul><li>Disconnect between departments </li></ul>
  4. 4. Going electronic <ul><li>2008 </li></ul><ul><li>MOH call for submissions for pilots to improve access to diagnostic services </li></ul><ul><li>NPIGG support to convert paper to electronic </li></ul><ul><li>Healthlink contracted to produce 3 e-forms based on Hutt DHB e forms in use </li></ul><ul><li>March 2009 </li></ul><ul><li>Release of e-referral platform consisting of a colorectal, breast and generic forms </li></ul>
  5. 5. After 6 months we thought… <ul><li>Gains in referral quality where to be found with customisation </li></ul>The generic form had little to offer other than providing an interim complete platform
  6. 12. Where are we up to? <ul><li>Outpatient referrals only </li></ul><ul><li>5 customised forms, all other referrals via generic template </li></ul><ul><li>Electronic processing at Central Referrals Office (central processing for ALL referrals) </li></ul><ul><li>Standardised referral processing across services </li></ul><ul><li>Printing of referral at service level </li></ul>
  7. 13. Outcomes of our customisation…
  8. 14. The Colorectal form
  9. 15. Process <ul><li>Understanding of referral types </li></ul><ul><li>Streamlined service to improve patient flow </li></ul><ul><li>Research to establish evidence base for referral content </li></ul><ul><li>Collaborative design of form - 1 °/2° care and IT vendor </li></ul><ul><li>“ road show” by lead clinician to engage users, what and why </li></ul>
  10. 16. Benefits to GPs <ul><li>Speed of use: 44% a lot faster </li></ul><ul><li>44% somewhat faster </li></ul><ul><li>12% same </li></ul><ul><li>Guidance: 62.5% very helpful </li></ul><ul><li>37.5% somewhat helpful </li></ul><ul><li>70% rated the usability of the form 8/10 or better </li></ul><ul><li>Uptake: overall e-referrals 60-70% </li></ul><ul><li>Colorectal form 85% </li></ul>
  11. 17. Benefits to specialist <ul><li>30% reduction in triage time </li></ul><ul><li>Improved a ccuracy of triage: </li></ul><ul><ul><li>100% of low risk patients required no 2 ° care intervention (6 month reviewed no further presentations </li></ul></ul><ul><ul><li>68% of cancer cases rated urgent vs. 50% pre e-referral </li></ul></ul>
  12. 18. Benefits to patients <ul><li>Accurate prioritisation means right queue </li></ul><ul><li>But…no change in time frame from referral to diagnosis </li></ul><ul><li>( function of inconsistent application of processes and capacity constraints) </li></ul>
  13. 19. Why has it worked well? <ul><li>Clearly defined and clinically important problem </li></ul><ul><li>Full service review </li></ul><ul><li>Evidence based form content </li></ul><ul><li>Collaborative form design </li></ul><ul><li>High engagement and education from specialist for GPs </li></ul><ul><li>BUT = TIME and MONEY </li></ul><ul><li>(and there’s improvements still be made) </li></ul>
  14. 20. The breast form
  15. 21. Process <ul><li>Un-used paper referral form used as clinical starting point </li></ul><ul><li>Meeting with triage staff and GPL, design based on Colorectal form </li></ul><ul><li>Email communication with the IT vendor </li></ul><ul><li>Released after letter sent to all GPs about the service changes and the new form </li></ul>
  16. 22. But…. <ul><li>Not meeting needs of either GPs or service </li></ul><ul><ul><li>Did not support all referrals types </li></ul></ul><ul><ul><li>Information supplied impeded prioritisation </li></ul></ul><ul><li>Version 2 developed after an informal meeting with a small GP group and triage staff </li></ul>
  17. 23. How is it going (GPs)? <ul><li>Slower to generate for some referral types than the paper system </li></ul><ul><li>“ a bit clunky” to use, doesn’t reflect the normal GP work flows </li></ul><ul><li>“ It’s OK” </li></ul>
  18. 24. How is it going (service)? <ul><li>Conflicting tick box and free text information </li></ul><ul><li>-> Slower to prioritise </li></ul><ul><li>Reduction in free text clinical information </li></ul><ul><li>-> loss of information </li></ul><ul><li>Clinical information clearer in paper version but supporting information (medication and problem lists) better. </li></ul>
  19. 25. Why it didn’t work well <ul><li>Problems with paper referrals not clearly defined </li></ul><ul><li>Patient referral types not defined </li></ul><ul><li>Inadequate collaborative design process </li></ul><ul><li>Inadequate GP engagement and education </li></ul><ul><li>Poor process = poor gains </li></ul><ul><li>Should we have done it? </li></ul>
  20. 26. The generic form <ul><li>What has it given us? </li></ul>
  21. 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
  22. 28. GP benefits <ul><li>Faster for GP </li></ul><ul><li>Anecdotal reports of referral done frequently at time of consultation </li></ul><ul><li>Reduction in after-hours work load </li></ul><ul><ul><li>95 % completed Monday-Friday </li></ul></ul><ul><ul><li>75% of these between 8am and 5pm </li></ul></ul><ul><ul><li>“ they have revolutionised my referral work ” </li></ul></ul><ul><ul><li>Dr A Miller </li></ul></ul><ul><li>Provided a standard work flow </li></ul>
  23. 29. More GP benefits <ul><li>Improved security: </li></ul><ul><ul><li>real time acknowledgement of receipt </li></ul></ul><ul><ul><li>No referral losses </li></ul></ul><ul><li>Decision support available: </li></ul>
  24. 30. Hospital benefits <ul><li>Eliminated faxed referrals to OPC </li></ul><ul><li>Improved security </li></ul><ul><li>Provided ability to audit </li></ul><ul><li>Improved demographic data inclusion </li></ul><ul><li>Standardised presentation </li></ul><ul><ul><li>improved accessibility of information to ALL groups </li></ul></ul><ul><ul><li>faster and easier to process </li></ul></ul>
  25. 31. Patient benefits? <ul><li>Clinical referral information: </li></ul><ul><ul><li>an initial drop , now neutral </li></ul></ul><ul><li>More consistent clinical information: </li></ul>Medication list Problem list Paper referral 55% 55% Generic e-referral 100% 100%
  26. 32. An un-intended spin off.. <ul><li>Standard presentation stimulated hospital clinicians interest referral quality and data integrity, prompted us to quantify </li></ul><ul><li>Unmasked errors: </li></ul><ul><ul><li>Problem list: 56% error rate </li></ul></ul><ul><ul><li>Medication list: 46% error rate </li></ul></ul><ul><ul><ul><li>of these 78% were clinically significant </li></ul></ul></ul>
  27. 33. Summary
  28. 34. <ul><li>Electronic referrals out perform paper ones </li></ul><ul><li>The generic form: </li></ul><ul><ul><li>enables rapid deployment of a electronic system </li></ul></ul><ul><ul><li>offers GPs a consistent, faster and more secure work flow that is easily adopted </li></ul></ul><ul><ul><li>Has benefits to all hospital staff and patients </li></ul></ul><ul><ul><li>Minimal change with significant gain </li></ul></ul>
  29. 35. Asking GPs to make yet more change……
  30. 36. Customised forms can add value but….. <ul><li>Referral security and information integrity are higher priorities to address. </li></ul><ul><li>Only consider </li></ul><ul><ul><li>Once there is a clearly identified need </li></ul></ul><ul><ul><li>After the patient referral pathways are clearly defined </li></ul></ul><ul><ul><li>By those that do the work </li></ul></ul>
  31. 37. Customised forms… <ul><ul><li>Require good clinical engagement to get buy in and good use: </li></ul></ul><ul><ul><li>what problem are we attempting to resolve </li></ul></ul><ul><ul><li>what is the process to evolve them </li></ul></ul><ul><li>Are continuous improvement projects </li></ul><ul><ul><li>Are very resource hungry </li></ul></ul>
  32. 38. Recommendations <ul><li>Introduce a generic platform “to the front door” </li></ul><ul><li>Address problems at the GPs end while addressing hospital processes </li></ul><ul><li>Consider customisation only once we have a robust platform. </li></ul><ul><li>Undertake as part of a service review process that includes GPs </li></ul>
  33. 39. Our future priorities
  34. 40. <ul><li>Referral security: </li></ul><ul><li>Incremental movement towards a full end to end solution </li></ul><ul><li>Referral quality: </li></ul><ul><li>Further evaluation of our current forms including feedback from all users </li></ul><ul><li>Work with GPs/PHO to improve data quality from PMS </li></ul><ul><li>Add acute referrals to the platform </li></ul><ul><li>Customisation only if a need is identified as part of a service redesign process </li></ul>
  35. 41. <ul><li>What about DHB collaboration? </li></ul>
  36. 42. Acknowledgements <ul><li>NPIGG </li></ul><ul><li>Hutt DHB </li></ul><ul><li>Mr Mark Sanders General Surgeon </li></ul><ul><li>Healthlink </li></ul><ul><li>The GPs of Northland </li></ul><ul><li>HINZ </li></ul><ul><li>Further information: </li></ul><ul><li>[email_address] </li></ul>