eReferral Strategy White Paper

 eReferral Strategy
White Paper
Clearing the
Co m m u n ic a tio n s F o g
Dec 2011:
This paper was written on behalf of the Champlain, South East and Central East LHINs. It is
intended to stimulate further discussion, will serve as a foundation for the next phase of the project,
and as such, it will evolve. Readers with input and/or questions should contact the author:
Glenn Alexander
Chief Information Officer
Champlain and South East Local Health Integration Networks
613.747.3244
[email protected]
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Table of Contents The Origins of Our Understanding ..................................................................................... 4
A Clearer Perspective ......................................................................................................... 5
The Referral Workflow and Stakeholder Perspectives ....................................................... 6
The Workflow .................................................................................................................. 6
The Patient’s Perspective ................................................................................................ 7
The Primary Care Physician’s Perspective .................................................................... 8
The Specialist’s Perspective .......................................................................................... 10
Other Considerations .................................................................................................... 13
The Administrative Personnel’s Perspective ............................................................. 13
Other Initiatives ......................................................................................................... 14
The Value of an eReferral / eConsultation Services ......................................................... 15
The eReferral Checklist .................................................................................................... 16
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The Origins of Our Understanding
Since 2009, the Champlain, South East
and Central East Local Health
Integration Networks (LHINs) have
implemented pilot projects with the
purpose of exploring the potential of
eReferrals.
In 2010 and 2011, the Champlain LHIN
successfully established a direct
connection between specialists and
primary care physicians (PCPs) through
its Building Access to specialists
Through eConsultation (BASE) Project.
This allowed them to explore treatment
options for patients without the patients
needing to see the specialist. The BASE
project examined the benefits of this
arrangement to the patients, the PCPs,
and specialists.
In addition, this project noted lessons to
be learned for a much broader eReferral
Strategy. The feedback received on this
project has been very positive. Often,
when specialists hear about the project
from their peers, they invariably ask
whether they can join.
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In 2011, the South East and Central East
LHINs, through their eReferral Pilot
Project, provided a solid technical
infrastructure to enable PCPs to refer
patients to specialists without the need
for faxes and paper. This project
examined the role of technology in
dealing with known referral challenges,
information shortfalls, and opportunities
for process improvement. Again,
feedback about the project from
clinicians has been excellent and
supportive of expansion.
The Canadian Medical Association held
a day-long planning session in January
2011, Streamlining Patients Flow from
Primary to Specialty Care, with a large
group composed of physicians and
specialists. This session’s overall
objective was to gain feedback from
these two groups on how best to
implement changes to the referral system
in Canada. This session explored the
pros and cons of the existing referral
processes and identified elements of an
eReferral Strategy important to these
stakeholders.
In addition, the Champlain LHIN has
been working closely with the Academy
of Medicine of Ottawa to identify the
needs and priorities of physicians in our
region for a more efficient and effective
referral process. The input received was
invaluable to our understanding of the
clinicians' views.
A Clearer Perspective
As a result of the insights provided by
the initiatives described above, we have
new and exciting perspectives on what
works and does not work for the patient,
the PCP, and the specialist.
This white paper enunciates these
insights
and
provides
helpful
information in building an effective
eReferral Strategy. This white paper is
about clearing the “communication fog”
associated with navigating the health
care system.
At this paper’s conclusion, we offer a
checklist for consideration by those who
wish to develop an eReferral solution in
their jurisdiction. This checklist will:

Help keep the projects focused on
what is important to the users of
those eReferral Systems; and

Ensure their eReferral Strategy
evolves over time, is comprehensive,
and responsive to the needs of the
patient, PCPs and specialists.
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The Referral Workflow and Stakeholder Perspectives
The Workflow
Below is a graphic that shows a generic referral process. It was designed to be illustrative of the significant steps and to serve as a
reference point for material to follow.
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The Patient’s Perspective
As the chart on the previous page
shows, the Patient touches the referral
process four times over the course of
the referral.
A patient’s good or bad perception of
the referral process is determined by:

The length of the wait for the
appointment notification

Their expectation about the length
of that wait, and

Their anxiety about their health.
If patients wait an unexpectedly long
time, their anxiety increases, and they
often fear their referral is lost and they
have been forgotten. PCPs comment on
the number of anxious patients who call
them asking whether they have heard
anything about their appointment. From
the patients' perspective, the PCP's
office personnel are seldom helpful. A
good eReferral Strategy will address the
issue of keeping patients informed on
the status of their referral with a
notification option (i.e., notifying the
PCP or having a place the patient
themselves can look it up).
Many patients travel long distances to
see specialists. For many, this is an
important consideration because of their
need to organize transportation. For
them, it is important to consider their
travel time when organizing referrals.
Wherever possible, they would like to
have tests done locally in advance of
the specialist visit. In this way, they do
not have to travel long distances
unnecessarily.
A referral strategy or project should
provide information to the PCP on the
specialists' locations. In this way, the
patient has the option to pick a service
closer to home.
Based on existing research, as well as
actual data gathered from the
Champlain BASE project, somewhere
between 25 and 40% of referrals may
be avoided if PCPs and specialists have
an effective means of communication
regarding patient cases. This would
mean avoidance of unnecessary travel
for patients in some cases, as well as
ensuring a more effective visit when
required.
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The Primary Care Physician’s Perspective
An interesting feature of the workflow
chart on the previous page is the PCP's
perspective, as s/he touches the referral
process four times. The PCP sends the
referral request to the specialist and
typically does not receive any feedback
until the specialist report is mailed or
faxed to them, often well after the
patient has been seen by the specialist.
guiding care at any particular point when
physicians and specialists are beginning
to work together.
PCPs have much to say about the
information gaps associated with
referrals. Many physicians do not know
the names of the specialists in their
geographic area and refer to the few with
whom they have had previous dealings.
It is little wonder that the PCP’s office
personnel are unable to help patients
when they call seeking information on
the status of their “lost” referral. From
the workflow, above, the PCPs know
less about the status of the referral than
the patient!
Obviously, providing physicians with
early feedback on the date that the
specialist will see the patient will be an
important part of any eReferral project.
Although the physicians do not mind
passing scheduling information along to
the patients, they do not want to act as a
"go-between" should the date selected
by the specialist be unworkable for the
patient. Some mechanism to reschedule
would be helpful.
In general, ongoing feedback is
important for the coordination of the
management of the patient care. As an
example, confusion can arise when
trying to determine who is in charge of
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If the specialists they know have
particularly long wait-times, their
patients will be waiting unnecessarily
long to see a specialist. Complicating the
referral process is the challenge they
have in identifying the subspecialty of
the specialists. This information gap can
result in unnecessary delays for the
patient and frustration for the physician
as the physician and specialist sort
through the referral information only to
discover that the specialist will not see
the patient.
A well-designed eReferral Project /
Strategy will include a physicians’
directory containing information such as
the specialists’ specialty, subspecialties,
location, and wait-time information.
The ongoing management of the data in
the physicians’ directory is particularly
important and can be problematic. The
catalogue should have reasonably
accurate
wait-time
information.
Presently, the wait-time information
collected by the Ministry of Health and
Long-Term Care does not cover all parts
of the patient’s wait, so something new
is needed.
At this point, the most accurate way to
maintain the data may be to build the
tracking mechanism into the eReferral
System either through scheduling
functionality or monitoring each referral.
In that way, the data is up-to-date at all
times and is based on the experiences of
the most recent clients. Obviously, the
accuracy of this method grows as
eReferral system becomes the chief
source of referrals for specialists.
Finally, the catalogue information
should reflect changes in specialist
practices. In this way, as specialists
leave the area, shift subspecialties, or
cease practice, the information in the
database remains relevant. Perhaps,
specialists’ staff could do this, since this
information does not change often, is
known to them, has a revenue impact,
and has an influence on which patients
they see.
Another question to be addressed by a
good eReferral Strategy is the role that
central intake may play in helping PCPs
refer patients to specialists. At its
simplest, a central intake function at a
site would eliminate the need for PCPs
to pick a specialist when there are a
number working out of a single location.
The PCP could refer to a site and site
personnel would then transfer the
referral to the appropriate person. At its
most complex, a region-wide central
intake service benefits everyone by
balancing the wait-times between
specialists,
coordinating
services
between
sites,
and
reducing
administrative inefficiency by reducing
the number of duplicate referrals. The
PCP simply refers patients to a
centralized site which helps the patient
find a provider, with an appropriate
balance
between
wait-time
and
proximity to their home.
Physicians refer to community-based
services through the Community Care
Access Centres and, on occasion,
directly. Physicians have requested that
the eReferral Strategy consider all of the
locations to which physicians refer.
More than 40% of physicians in Ontario
have an electronic medical record or
clinical management system. This
number is expected to grow significantly
in coming years.
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Physicians with clinical management
systems (EMRs) have asked that the
eReferral Strategy include integration
into their existing systems. In this way,
they can launch a referral without the
need to log onto another system, thereby
better aligning with their existing
workflows. PCPs who do not have
clinical management systems would like
a system that allows them to participate.
In addition, physicians that practice in
multiple locations have asked that the
eReferral system allow them to access
their referrals from any location.
The Specialist’s Perspective
Being at the center of the referral
workflow, one would expect that the
specialists receive all of the information
they need, are factored into all parts of
the referral process and touch the referral
process as many times as necessary.
Interestingly, specialists only touch the
process three times. They have indicated
information gaps exist, as well as
opportunities for improvement.
Specialists have indicated that a properly
executed eReferral System would
include the introduction of clinical
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pathways and reminders. This would
provide PCPs with information to help
them
with
basic
triaging
for
appropriateness before referring a
patient, thereby reducing the number of
patients visiting specialists prematurely
or unnecessarily.
In addition, the system could provide
reminders to the PCPs concerning
testing that they should perform before
the patient makes their first visit to the
specialist.
With this in place, the specialist benefits
by getting all the right information and
preliminary testing done at the PCP level
before the first specialist appointment
occurs. If all the right information is in
place and testing done ahead of time, the
specialist and patient could be saved
weeks of delays while the patient has the
necessary
testing
done.
System
efficiencies increase if the patient’s visit
to the specialist occurs with information
already in place for the specialist to
complete their work in one visit.
In fact, Specialists have noted that with
good
communication
established
between themselves and physicians, it is
not always necessary for the specialist to
see the patient. The BASE project in the
Champlain LHIN demonstrated the
clinical and wait-time benefits to the
patient of incorporating eConsultations
in an eReferral Strategy.
amount of material submitted can range
from a page or two of relevant
information, to tens of pages of
unnecessary information. Complicating
the referrals are any handwritten notes.
The quality of these referrals range from
excellent to vague clinical questions to
unreadable. Any eReferral Project will
eliminate illegible text, but a good
strategy will ensure the quality of
information in an eReferral is acceptable
and the clinical question being asked is
clear.
PCPs told the project evaluation team
that more than 85% of the completed
eConsultations had significant value to
the physician and the patient. Indeed, in
41% of the eConsultation cases, a
referral was originally contemplated but
avoided as a result of the service.
In these examples, patients were not
required to wait weeks or months before
treatment could begin. Rather, their
physician could start treatment within a
few days of seeing the patient.
EConsultations incorporated into any
eReferral strategy creates policy issues
that need to be addressed, including
payment to the specialist for the service
offered. Specialists participating in
BASE received compensation for time
spent on eConsultations through onetime project funds.
The quality and content of the referral
should be considered as part of any
eReferral Strategy. When a physician
uses a clinical management system to
create the material for a referral, the
Specialists have indicated their role is to
assess the patient's condition and
determine an appropriate course of
action. As such, they have few concerns
about their role in determining the
appropriateness of treatments suggested
by the PCP.
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As an example, surgeons do not mind
providing feedback to PCPs that the
patient is not an appropriate candidate
for surgery; however, they indicate that
this feedback should happen as early as
possible. Many specialists suggest that
any eReferral Strategy contain an
upfront check for appropriateness to
better manage their wait lists and help
manage patient expectations. Therefore
any eReferral Strategy should consider
implementing clinical pathways that will
help the physician determine whether a
particular
referral
is
warranted.
Similarly, any eReferral Strategy should
provide ways that PCPs can flag the
urgency of a particular referral to the
specialist.
There is one specialty service rendered
to the patients where the specialist and
the patient never meet: Diagnostic
Imaging. The need for "appropriateness"
testing is especially evident for
Radiologists' services. Recent studies
suggest that almost 20% of diagnostic
imaging tests could be eliminated with
appropriate support for PCPs, as they
refer patients for these services.
During the triage phase of a referral,
specialists (or clinical staff reporting to
them) determine the triage level. This
information needs to be passed along to
the schedulers, and made available to the
referring physician.
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The eReferral Strategy should:

Track the number of completed
referrals, the wait-time associated
with each referral, the number of
outstanding referrals, and

Provide the ability to look up the
status of a particular patient's
referral.
Most specialists do not have clinical
management systems, although this is
changing. For those specialists who have
clinical management systems there is a
need to integrate the eReferral system
into their existing platforms.
Like PCPs, specialists do not want to log
on to multiple systems. Similarly, many
specialists are now participating in
Computerized Physician Order Entry
(CPOE) initiatives within the hospitals
where they practice. An eReferral
Strategy should consider the need to
build interfaces to those systems.
PCP and specialist calendars are
particularly busy. As a result, when one
party needs to contact another, they
often are met with voicemail. The
eReferral Strategy should allow for an
asynchronous dialogue between the two.
Perhaps one of the most exciting
opportunities that an eReferral strategy
can bring is the ability to provide
feedback from the PCP to the specialist.
In a paper-based referral system, the
specialist often does not know whether:



Their advice was taken
Their advice was adequate, and
The patient benefited from the
treatment plan.
This type of feedback would be wellreceived by specialists and could
improve quality of care.
Other Considerations
The Administrative Personnel’s Perspective
Supporting the eReferral Strategy are
administrative
personnel
who
coordinate bookings, schedules, and
support services to the patient. Their
advice should be sought to ensure that
the final solution is the most efficient
and effective one.
A successful strategy will require a
smooth implementation and adoption
plan, ensuring minimal disruption to the
normal operation of the PCP and
specialist clinics. As such, the solution
would be expected to allow for both
“traditional” referrals and the new
eReferrals to be initiated, received, and
processed for a period of time.
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Other Initiatives
There are a number of eReferral and
eReferral-like initiatives planned or
underway in Ontario. These include
Resource Matching and Referral
Projects, community based referral
projects such as Integrated Referral
Information System, in the Champlain
LHIN, and hospital-based CPOE
initiatives. An eReferral Strategy should
look to these for alignment, integration,
and efficiency opportunities. In addition,
there may be an opportunity to transfer
clinical
pathways,
specifications,
processes, and referral forms from one
project to another.
Clinicians have told us that triaging
patients requires a combination of basic
information suitable for all referral
types, as well as, information unique to
the specialty. Developing these could be
a sizeable undertaking. The table, below,
indicates there are 43 specialties in
Ontario. The clinical pathways that aide
in triaging the patient, should be tuned to
the specialists needs and derived from
extensive consultation with them.
Estimated Number of Referrals, By Specialty (2009-10, Ontario)1
Specialty
1. Diagnostic radiol.*
2. Internal Medicine
3. General Surgery
4. Obstetrics & Gyne
5. Orthopaedic Surg
6. Dermatology
7. Otolaryngology
8. Paediatrics
9. Ophthalmology
10. Urology
11. Cardiology
12. Neurology
Referrals
1,202,015
1,025,045
655,866
527,492
482,587
467,170
386,960
339,983
283,102
270,113
252,843
222,747
Specialty
Referrals
13. Gastroenterology
200,269
14. Anaesthesia
196,550
15. Plastic Surgery
196,111
16. Psychiatry
190,128
17. Respiratory Disease
83,880
18. Physical Medicine
82,209
19. Neurosurgery
44,226
20. Therapeutic Radiol
44,047
21. Rheumatology
39,923
22. Pathology
30,069
23. Haematology
28,256
24. Cardio & Thorac Surg
23,030
Specialty
Referrals
25. Geriatrics
20,922
26. Endocrinology
19,080
27. Thoracic Surgery
18,483
28. Nephrology
11,008
29. Infectious Disease
8,700
30. Clinical Immunology
8,019
31. Vascular Surgery
5,635
32. Medical Oncology
5,581
33. Genetics
3,100
34. Nuclear Medicine
902
35-38. 4 other specialties
531
Total
7,376,582
Proxy for number of referrals is based on count of specialist consultations (fee schedule code class=A1-specialist consultations).
Note: Based on physician specialty at time of billing, which may differ from usual specialty. Source Intellihealth, Medical Services
Summary Table, accessed Sept 2011. * Diagnostic radiology numbers also include age 18+ priority 2 and priority 3 (i.e. non-urgent,
outpatient) scans as reported to the Wait Times Information System in 2010-11.
1
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The Value of an eReferral / eConsultation Services
The benefits of eReferrals and eConsultations by stakeholder include:
For the Patients:
For All Stakeholders:

Reduced wait-times.


Improved experience through better
coordination of services.
Ensures a more effective visit to the
specialist (from both the patient and
PCP perspectives)


Reductions in unnecessary or
inappropriate testing and referrals.
Easy to use tools for the PCP and
specialists’ practices.

Improved patient, PCP, and
specialist satisfaction with the
referral process.

Improved communications between
the patient, PCP and specialist.
For the Specialists and PCPs:

Improvements in the quality of
referrals going to specialists.

Easier and faster triaging of patients
for the specialist.

Standardized tools that help identify
appropriate referral options by
identifying the referral criteria, the
ancillary tests needed and the
referral urgency for the PCPs.

Reductions in the PCPs' referral
administration costs.

Reductions in the time that PCPs
take to find the right specialist to
help them.

Sustainable and cost effective
support systems for PCPs and
specialists.

Ability to track referrals and referral
statistics such as wait-times 1 and 2,
referral volumes, etc for the PCP
and specialist.
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The eReferral Checklist
The list below summarizes the requirements to be considered
when developing an eReferral strategy or planning for an
eReferral project. Planners would scope their initiative to a size
and complexity that they are comfortable with using the list
below.
At a later date, their project’s expansion could include new
requirements from the list. Thus, the roadmap for their project
would include functionality growth and improved services to
patients, primary care providers, and specialists.
 Have you established an up-to-date
regional Physicians’ directory for
physician use, and are processes in
place to maintain it?
 Is there a platform for asynchronous
communication between PCPs and
specialists? (Leaving messages for
each other, asking questions of each
other. Note: This allows for a more
flexible interaction and removes the
need to be too prescriptive in the
eReferral forms.)
 Have you gathered consensus with
PCPs and specialist on what
information specialists need to
properly triage a patient?
 Have the specialists and PCPs
agreed to a clinical pathways that
ensure required tests are complete
and available - before a referral
occurs?
 Is there an up-front check for
appropriateness in the eReferral
environment?
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 Can the system transmit images and
other attachments, embedded with
the referral?
 Can the PCPs flag eReferrals for
urgency?
 Have you incorporated the support
for eConsultations in your eReferral
environment and examined
compensation for the specialists?
 Have you considered the possibility
of establishing a Central Intake
function?
 Have you thought through the
impact that the eReferral System
will have on the administrative
support staff?
 Can your eReferral solution
smoothly co-exist with the
traditional referral processes that
may need to be maintained for some
period of time?
 Have you established a feedback
mechanism to the patient and
physician to inform them of the
anticipated appointment date with
the specialist and allow the patient to
change the date should it be
unworkable?
 Is the eReferral system able to
integrate with physician and
specialist clinical management,
hospital, and CPOE systems?
 Have clinical pathways been created
for each specialty area and signed
off by the specialists?
 Have you included a mechanism for
the specialists and the PCPs to
review the status of eReferrals?
 Have you considered setting up
referral paths to community
agencies?
 Have you incorporated a feedback
mechanism from PCPs to specialists
so that they can report on whether
their advice was useful or not,
whether the patient care was
improved, and whether the advice
was clear?
 Have you looked at other initiatives
in your geographic area which might
impact the same people?
 Have you structured the system to
collect and report the various wait
times?
 Have you considered how the
system and reporting might help
with an overall plan for wait list
management?
 Have you considered how the
system and reporting might help
with resource management, e.g.
booking procedure rooms etc?
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