Introduction of Electronic Referral from Community Associated with More Timely Review by Secondary Services

Summary

Background: Electronic referral (eReferral) from community into public secondary healthcare services was introduced to 30 referring general medical practices and 28 hospital based services in late 2007.

Objectives: To measure the extent of uptake of eReferral and its association with changes in referral processing.

Methods: Analysis of transactional data from the eReferral message service and the patient information management system of the affected hospital; interview of clinical, operational and management stakeholders.

Results: eReferral use rose steadily to 1000 transactions per month in 2008, thereafter showing moderate growth to 1200 per month in 2010. Rate of eReferral from the community in 2010 is estimated at 56% of total referrals to the hospital from general practice, and as 71% of referrals from those having done at least one referral electronically. Referral latency from letter date to hospital triage improves significantly from 2007 to 2009 (p<0.001), from a paper referral median of 8 days (inter-quartile range, IQR: 4–14) in 2007 to an eReferral median of 5 days (IQR: 2–9) and paper referral median of 6 days (IQR: 2–12) in 2009. Specialists upgrade the referrer-assigned eReferral priority in 19.2% of cases and downgrade it 18.6% of the time. Clinical users appreciate improvement of referral visibility (status and content access); however, both general practitioners and specialists point out system usability issues.

Discussion: With eReferrals, a referral’s status can be checked, and its content read, by any authorized user at any time. The period of eReferral uptake was associated with significant speed-up in referral processing without changes in staffing levels. The eReferral system provides a foundation for further innovation in the community-secondary interface, such as electronic decision support and shared care planning systems.

Conclusions: We observed substantial rapid voluntary uptake of eReferrals associated with faster, more reliable and more transparent referral processing.

Keywords

User acceptance and resistance - provider-provider communications - process improvement

• References

• 1 National Health IT Board. National Health IT Plan: Enabling an integrated healthcare model. Wellington http://www.ithealthboard.health.nz/content/national-health-it-plan 2010 September.
• 2 Acland R, MacKay P, Moller P. Working with others. Cole’s Medical Practice in New Zealand (2011 ed.), Chapter 14. Wellington: Medical Council of New Zealand; 2011
• 3 New Zealand Health Information Service.. Glossary for data dictionaries. 2008 [updated 2008; cited 2011 02–02]; Available from: http://www.nzhis.govt.nz/moh.nsf/pagesns/241.
• 4 Nicholson C, Jackson CL, Wright B, Mainwaring P, Holliday D, Lankowski A. et al. Online referral and OPD booking from the GP desktop. Aust Health Rev 2006; 30 (03) 397-404.
• 5 Blue Care Network of Michigan.. User guide: e-referral on the iEXCHANGE system. 2010 [updated 2010; cited 2011 02–02]; Available from: http://ereferrals.bcbsm.com/ereferral_user_guide.pdf.
• 6 Shaw LJ, de Berker DA. Strengths and weaknesses of electronic referral: comparison of data content and clinical value of electronic and paper referrals in dermatology. Br J Gen Pract 2007; 57 (536) 223-224.
• 7 Cannaby S, Wanscher C, Pedersen CD, Voss H. The cost benefit of electronic patient referrals in Denmark: full report. ACCA and MedCom in collaboration with the European Commission Information Society Directorate –General. 2005
• 8 Hysong SJ, Esquivel A, Sittig DF, Paul LA, Espadas D, Singh S. et al. Towards successful coordination of electronic health record based-referrals: a qualitative analysis. Implement Sci 2011; 6 (01) 84.
• 9 Heimly V. Collaboration across organizational boarders, the referral case. Stud Health Technol Inform 2010; 157: 106-111.
• 10 Schoen C, Osborn R, Doty MM, Squires D, Peugh J, Applebaum S. A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences. Health Aff (Millwood) 2009; 28 (06) w1171-w1183.
• 11 Health Information Standards Organisation.. Referrals status and discharges. New Zealand Ministry of Health; 2010 [updated 2010; cited 2011 18/05]; Available from: http://www.ithealthboard.health.nz/referrals-status-discharges.
• 12 Glaser BG, Strauss AL. The discovery of grounded theory; strategies for qualitative research. Chicago: Al-dine Pub. Co.; 1967
• 13 McNiff J, Whitehead J. Action research: principles and practice (2nd ed.). London: Routledge; 2002
• 14 IT Health Board.. Health Information Security Framework (HISF). (URL: http://www.ithealthboard.health.nz/hisf , last accessed 19 June 2011); 2009
• 15 IT Health Board.. Online Forms Architecture Technical Specification. (URL: http://www.ithealthboard.health.nz/online-forms-architecture-technical-specification ); 2010
• 16 IHE Wiki. Query for Existing Data Profile. (URL: http://wiki.ihe.net/index.php?title=Query_for_Existing_Data_Profile last accessed 19 June 2011); 2008
• 17 Patterson V, Humphreys J, Henderson M, Crealey G. Email triage is an effective, efficient and safe way of managing new referrals to a neurologist. Quality and Safety in Health Care 2010 2010; 19 (05) 1-4.
• 18 Mitchell GK, Tieman JJ, Shelby-James TM. Multidisciplinary care planning and teamwork in primary care. Med J Aust 2008; 188 (08) S61-S64.