Guide #1 - PCP to Specialist ereferral

Guide #1 - PCP to Specialist ereferral

Executive Summary The Healthcare Executive s Guide to Streamlining Patient Flow New Accountability The mission-critical challenge facing today s healthcare executive is to find new ways to improve patient care and access, and lower costs. Achieving this is no small task. Staff shortages, long wait times, silo mentalities, and shifting system benchmarks have handcuffed administrators to unsustainable balancing acts. Solution The solution lies in economy of scale; and governments are commanding acute changes in health delivery to get there. Chief executives are being called to lead this global transformation; and their performance is being measured by their ability to reform. These thought-delivery leaders, skilled at influencing competing agendas, are finding solutions by leveraging technology to respond to access, cost, quality, and patient satisfaction issues. They are heroically revolutionizing how healthcare is delivered. Streamlining Patient Flow The number of manual patient referrals exchanged everyday between healthcare providers is astounding. These inefficient and labour-intensive methods result in unnecessary cost, delay, error, and frustration. As more people engage with health systems more often because of demographic shifts and health complexities, patient referrals will continue to rise. Streamlining patient flow: Reduces operating costs; Improves patient outcomes; and Increases community satisfaction. Results Automated patient flow practices such as ereferral delivers the critical change needed to achieve real benefits for patients, their families, overworked front-line workers, and health systems. This white paper looks at current referral practice and how the ereferral solution dramatically improves patient flow to: Reduce cost; Increase productivity; Align with clinicians; and Maximize ROI. A list of ereferral benefits and a practical guide to developing an ereferral strategy is included at the end of this discussion. Millions of manual (paper, fax, e-mail, and phone) patient referrals and service orders are exchanged between healthcare providers each year in Ontario. Source: Ontario Continuing Care e-health 2011 Page 2 of 10

Referral Flow: The Patient The Healthcare Executive s Guide to Streamlining Patient Flow In a typical referral process the patient engages four times - ample touch points to form a lasting opinion of a healthcare system. Differing expectations on appointment notification waits, patient anxiety, and poor understanding of the referral process itself determine a patient s level of satisfaction with the referral experience and their perception of the quality of care received. Issue: Long waits for referral appointment When a patient waits (what they perceive to be) too long for a referral appointment, he/ she fears two things: that their referral is lost; or that they have been forgotten. PCPs (Primary Care Physician) that use a manual (paper, fax, e-mail, and phone) referral system regularly face lost productivity dealing with anxious patients wondering about their appointments. Most of the time, PCP staff are just as uninformed and unable to help. ereferral Solution: Automatic patient notification The benefit of an ereferral process is that it can provide referral status notifications directly to PCPs; or it can point the patient to an online site where h/she can track their own referral status. Keeping patients informed about the stage of their referral is a key to strong patient perception of the health system. Issue: Travel distance to see Specialist Specialists usually concentrate in larger urban areas where specialized facilities and equipment are readily available. Many patients must travel long distances to see them. Because of their need to organize transportation, this often becomes an important consideration when arranging patient referrals. Wherever possible, patients usually prefer to have advance tests done locally to avoid unnecessary travel. ereferral Solution: Patient Choice The benefit of an ereferral process is that it can give the patient choice by providing the PCP with the locations of specialists so that a patient has the option of choosing a service closer to home. Current research indicates that effective communication between PCPs and specialists regarding patient cases reduces considerably the number of patient referrals and increases the effectiveness of required visits. The Champlain BASE project found that between 25 and 40 percent of patient referrals could be avoided (and unnecessary travel reduced) when PCPs and specialists had an effective means of communication. Source: Ontario Local Health Integration Network ereferral Health Strategy 2011 Page 3 of 10

Referral Flow: The Primary Care Physician (PCP) Correspondingly the PCP (Primary Care Physician) also touches the referral process four times. As the front-line point of contact between patient and health system, information gaps associated with referrals result in unnecessary delays, frustration, loss of productivity, and cost pressures in the management of patient care. Issue: Information Gaps in Specialist Availability Many physicians do not know the names, specialties, or sub-specialities of the specialists in their geographical area. They often refer patients to the few specialists they either know or with whom they have had previous contact. When several PCPs refer patients to the same pool of specialists who may already have long wait times, the result is an unacceptably lengthy wait time for patient appointments. A further complication is that the specialist may refuse to see the patient if the referral information from the PCP does not meet the requirements of the specialist. This is often a result of the PCP s challenge identifying the specialist s sub-specialty. ereferral Solution: Searchable Directory The benefit of an ereferral process is that it can provide the PCP with a searchable, centralized, web-enabled directory tool and tracking system of specialists, their subspecialities, locations, wait times and contact information. As ereferral becomes the primary source of specialist referrals, ongoing accuracy of the database builds proportionally. The catalogue of information provides the clinician with those specialists that match to the patient s clinical need, and choice and geographical preference. As specialists leave the area, change subspecialties, or cease practice, the database would remain relevant. Specialist staff would be the most likely to update the system since this information is known to them, impacts revenue, and has an influence on which patients they see. Issue: Information Gaps in Referral Scheduling This typical scenario where a PCP office sends a referral request to a specialist by phone, fax, e-mail or letter results in a consistently similar situation where the PCP does not receive feedback from the specialist until the report has been faxed or mailed back to the PCN. By this time the patient has often already seen the Specialist. PCP office personnel lose hours of productivity each year tracking and following up on patient referrals. Physicians expect to share specialist scheduling information with patients but do not want to manage rescheduling when appointments are unworkable. ereferral Solution: Early Feedback on Specialist Appointments The benefit of an ereferral process is that it can provide PCP s with early feedback on specialist appointment dates and offers a rescheduling mechanism. PCPs can better manage the administrative process involved in patient referrals. This results in better patient care, higher productivity, and lower operational costs. 40% of older patients have multiple transitions within 30 days after the hospital discharge Source: Coleman 2004 Page 4 of 10

Issue: Intake Function Where there are several specialists working out of a central site, PCPs often have to choose a specialist to whom they refer a patient. If a busy PCP becomes familiar with one of the specialists, future referrals from that PCP are likely to continue to go to that specialist. This can create imbalance in the operations of the specialist site. ereferral Solution: Central Intake The benefit of an ereferral process is that it can be configured to provide either a sitecentral or system-wide central intake function that considers all of the locations to which physicians refer. This eliminates the need for the PCP to discern specialties. Their responsibility is simply to refer to a centralized specialty site that would balance wait times and proximity, coordinate services, monitor duplicate referrals, and reduce administrative inefficiency among referring PCP offices. The centralized site would relieve the PCP from most of the administrative tasks associated with finding a specialist for a patient. Issue: System Integration Primary Care Physicians are busy. Converting to an electronic medical record or clinical management system has been measured at best. The number of PCPs moving to a digital system is expected to rise, however, as the need for efficiency within the system continues to increase. Those physicians who already use electronic systems do not want to significantly alter their current workflows and those who would like a clinical management system want an easy transition. ereferral Solution: Easy Integration The benefit of an ereferral process is that it can easily integrate with current systems to provide PCPs with a one-stop approach to launching referrals. There is no need to log onto other systems; and referrals may be accessed from any location. Canadian readmission rates are 42% in patients >75 years Sources: Forster 2004; Conseil Canadien de la santé 2009 Page 5 of 10

Referral Flow: The Specialist Specialists are at the centre of the referral workflow. Interestingly they touch the process only three times. They too have identified information gaps in the current manual referral process and seek opportunities for improvement. Issue: Basic Triaging Specialists say they receive many inappropriate referrals from PCPs. Incomplete information, no preliminary testing, and incorrect specialty referrals result in premature (therefore duplicate) or unnecessary specialist visits. ereferral Solution: Clinical Pathways The benefit of an ereferral process is that it can display clinical pathways specific to a variety of specialties. It can also flag for testing reminders to help PCPs triage patients appropriately before referring to a specialist. The PCP can save both the specialist and patient weeks of delay by providing correct information and ensuring that preliminary testing is done before the specialist sees the patient. The ereferral process can also incorporate econsultations between a specialist and a PCP which can eliminate unnecessary referrals and improve wait times for the patient. Issue: Quality/Content of Referral Physicians using clinical management systems submit referral material ranging from condensed one or two-page summaries to lengthy pages of unnecessary information. Handwritten notes can complicate referrals. Disparities in the quality of referrals are stark and clinical vagaries are common. ereferral Solution: Standardization The benefit of an ereferral process is that referral quality can be standardized, illegible text eliminated, and referral urgency noted. A prepopulated content management system can pinpoint the clinical question being asked of the specialist and ensure a high and standardized quality of information is submitted. Issue: Diagnostic Imaging Diagnostic imaging is one specialty where the patient and specialist do not meet. Recent studies suggest that nearly 20 percent of diagnostic imaging tests could be eliminated if PCPs were appropriately supported, especially regarding radiology referrals. ereferral Solution: Referral Tracking The benefit of an ereferral process is that it can provide both radiology schedulers and PCPs the ability to track completed and outstanding radiology referrals and their associated wait times. It also provides a mechanism to quickly view the status of a patient s referral. econsultations between PCPs and Specialists can reduce the time a patient starts receiving treatment from weeks and months to a few days. Page 6 of 10

Issue: System Integration Although it is changing, most specialists do not have clinical management systems. For those who do, system integration is critical. ereferral Solution: One Platform The benefit of an ereferral process is that it can build an interface into one existing clinical management system platform. Busy specialists who also participate in electronic systems within hospitals where they practice can access one integrated system. Issue: Specialist/PCP Communication Both specialists and PCPs are extremely busy. Attempting to communicate with each other can be a particularly frustrating and time-wasting exercise when continually met with voicemail. ereferral Solution: Asynchronous Communication The benefit of an ereferral process is that it can facilitate asynchronous communication between two parties. Issue: PCP Specialist Feedback Specialists often do not know whether they have provided appropriate advice and patient care. ereferral Solution: Closed Communication Loop The benefit of an ereferral process is that it can complete the communication loop by prompting PCPs to enter information about whether specialist advice was adequate, undertaken and effective. Direct communication between hospital physicians and primary care physicians occurs infrequently (3%-20%) Sources: Schoen 2006; Kripalini 2007 Page 7 of 10

Referral Flow: Administrative Support The support staff that coordinate bookings, schedules and patient support services are critical to the success of an ereferral process. To minimize disruption, ereferral allows for gradual implementation and adoption in PCP and specialist clinics. ereferral is a dynamic process that can evolve over time to ensure maximum administrative efficiency, effectiveness and compatibility without increasing workload. Benefits of ereferral and econsultation For Patients Shorter wait times Better coordination. Better experience. Fewer inappropriate tests and referrals Referred to most appropriate specialist based upon clinical need, choice and geographical preference For Specialists/PCPs Improved referral quality Easier patient triaging Standardized tools and referral criteria Lower referral administration costs Reduced specialist search time Sustainable, cost-effective support systems Ability to track referrals and referral statistics For Health System More effective specialist visits Ease of use Improved communication Improved patient outcomes and satisfaction Ensures Equity of Access, Improved transparency regarding referral barriers, capacity gaps and demands Discharge summaries often lacked important information such as: diagnostic test results (missing from 33%-63%) treatment or hospital course (7%-22%) discharge medications (2%-40%) test results pending at discharge (65%) patient or family counseling (90%-92%) and follow-up plans (2%-43%) Sources: Schoen 2006; Kripalini 2007 Page 8 of 10

Practical Guide to Developing an ereferral Strategy The checklist below summarizes the requirements health executives should consider when planning for and developing an ereferral strategy for their system. Initiatives can be shaped to appropriate size and complexity and can include new prerequisites from the list as projects expand. Current physician s directory and a means to maintain it Platform for asynchronous communication between PCPs and Specialists Consensus with PCPs and Specialists on triage information Agreement between Specialists and PCPs on clinical pathways Preliminary check for ereferral appropriateness Ability to transmit images and embedded attachments with referral Ability of PCPs to flag urgent referrals Support for econsultation and established compensation policy for Specialists Central Intake function Impact on administrative support staff Co-existence with traditional process during transition period Patient/physician feedback mechanism for flexible Specialist appointment schedulings Integration with all Physician, Specialist and hospital clinical management systems into the larger EMR/EHR picture. Specialist-approved clinical pathways for each specialty area Mechanism for Specialists and PCPs to review ereferral status Consideration of referral flows to community agencies PCP Specialist feedback mechanism to report usefulness, clarity, and uptake of Specialist advice Impact of other area initiatives System structured to collect/report wait times System contributes to overall wait list management plan System contributes to resource management/bookings Inclusion of business intelligence functionality to provide information regarding the entire referral pathway along the care continuum Conclusion Technology is allowing health systems to leap into the future. The days of slow, inefficient fax and phone referrals are coming to an end. With ereferral, physicians can now call up, fill out, and send referral form templates electronically and track it all in electronic medical records. Doctors are seeing significant increases in patients getting the tests and screening necessary for prevention and to manage chronic conditions. ereferral is eliminating unnecessary work and increasing productivity resulting in reduced costs, improved patient care, and rising levels of public satisfaction. Page 9 of 10

Strata Health - Entrusted Strata Health leverages web technology to achieve dramatic patient flow improvement. Our customers have entrusted us with the job of achieving real and dramatic benefits for patients, their families and the world s devoted front line caregivers. We ve been entrusted to create patient flow solutions that really do deliver. Our Products The Strata PathWays suite of solutions is an exciting case in point. This online, real-time waitlist optimization system radically reduces the time that patients occupy acute care beds after they have been cleared for release into alternative community care streams. In use by health jurisdictions serving over 8 million Canadians, Strata PathWays seamlessly matches the specific needs of post-acute care clients with the particular resources and availability of providers in the community. Alberta Health Services Calgary Zone, for example, achieved an annual drop of 67% (from 120 to 40) in the number of acute bed clients waiting for appropriate community placement. Our Vision The ongoing evolution of Strata PathWays brings us closer each day to fulfilling our Vision: To be the global patient flow logistics thought and delivery leader, as judged by the leading Health Care organizations, clients and individuals who choose to partner with us. Click here to see our entire Brand Foundation. Our Clients The end users of our products front line health care workers who ve borne the brunt of complex and manual processes of patient flow management find our systems highly effective and easy to use. We deeply appreciate their approval, because it s our Mission to campaign for improvement by partnering with our customers. We do this by listening very carefully to them. And then by listening some more. So the patient management systems we deliver to them reflect their heartfelt input and solve the very real challenges they face every day. And if you listen to our customers, you ll hear their enthusiasm for our company: Outstanding customer care and service. They deliver on target and on budget. Great people, integrity, hard working they deliver. Amazing can-do and will-do attitude from all the Strata Health people. Our People So who are these Strata Health people? Operational in Canada, and the UK, we re a privately-held Canadian corporation of professionals with empathy for those who need care and intense respect for those who devote themselves to caring for others. To learn more visit www.stratahealth.com Page 10 of 10