eReferrals - National Health Information Priority Action Zones - Health Information Strategy Advisory Committee

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eReferrals
This document is an initial HISAC view of the ‘eReferrals’ Action Zone of the Health Information Strategy for New Zealand 2005 (HIS-NZ). Its purpose is to stimulate discussion and responses from health and disability sector practitioners, providers and funders, about the issues and opportunities associated with the improved use of existing and emerging information technologies and information management systems in the health and disability sector.

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Background
This Initial View is a HISAC informed ‘Straw Man’ and it does not claim to represent the final direction of the Action Zone. It is a starting point for the sector informed Preliminary Scope and Approach currently being prepared, by proactive engagement with the sector, for each Action Zone.red, by proactive engagement with the sector, for each Action Zone.

HISAC wants to see improved accuracy, clinical relevance, timeliness and efficiency in the referring of patients between practitioners around the sector. This will be achieved through improved clinical processes supported by the capture and sharing of better data. These changes will enable better patient journeys through the health system, created by a more collaborative approach to care planning.

A view of eReferrals in the future
Vision: Patients are referred to the right practitioner with the right information and receive the right response.
Strategy: Provide complete and relevant referral information electronically and make it available to practitioners involved in the patient’s care to allow prompt and appropriate clinical decision-making.

Features of eReferrals

HISAC envisages that a comprehensive eReferrals system will include these features:

eReferrals will be created according to an accepted standard and will be pre-populated from existing clinical information systems where possible.
All compulsory data fields will be completed before the eReferral is finalised and sent.
eReferrals will use structured codes to identify patients and practitioners, describe diagnoses, identify tests and results, and list medicines.
Coding may be supported by free text comments, images and videos.
Referrals will be made to and from a much broader range of organisations.
eReferrals will be electronically validated at source and at destination. Clinical decision support at source will be able to assist the validation process.
eReferrals will be tracked and electronic status reports provided as they are delivered to the correct practitioner (whether outside and within hospital settings). Receipt of the referral will be acknowledged electronically and alerts generated if service level timeframes are not met.
Paper-based referrals will be handled as an exception and captured into the electronic system at the first opportunity.
All of a patient’s referrals and status reports will be available to health practitioners involved in that patient’s care. All accesses will be authorised and audited.

Benefits from sector involvement in eReferrals
Patients and individuals will benefit from eReferrals as:

They will be more reliably informed about the status of their healthcare (e.g. by their GP. Have they been accepted for assessment at the public hospital?).
They will not have to provide the same information repeatedly to each practitioner they meet because practitioners will have access to a trusted electronic source of patient information.
They can rely on treating clinicians to have relevant and accurate data available to them; therefore practitioner mistakes, especially during handover, will reduce.
They will have improved access to appropriate services because there will be a faster response to their needs.

Health practitioners who refer patients to other services/practitioners will benefit from eReferrals as:

They will be prompted to provide consistent and relevant information on the appropriate referral form – not too much information but not too little. Wherever possible data fields will be automatically populated by the patient management system.
They will be able to add any text, diagrams, images or videos which they consider important.
They can rely on a system which is monitored for timeliness and won’t allow the referral to be lost – they won’t have to worry about tracking the referral manually.
They will be able to keep patients informed of the status of the referral and thus provide a better service to their patient.
They will have more efficient access to specialised knowledge. This in turn may mean more self-reliance and less need to refer patients.
There will be reduced administrative overhead, especially in phone calls, faxing and paper handling.

Health practitioners who receive referrals will benefit from eReferrals as:

They will have relevant and complete information upon which they can make reliable clinical decisions.
eReferrals will carry with them, or be linked to, a source of core patient data. This will allow multiple referrals for the same patient to be detected and tracked.
The tracking process will ensure that referrals are always processed in a timely way or that the referring practitioner and patient are informed of referral progress.
It will be easier to bring a multi-disciplinary team together / get a second opinion to help develop the patient’s care plan.
Incoming eReferrals can be managed efficiently and transparently.

Organisations responsible for delivery of health services will benefit from eReferrals as:

They will be able to monitor and assess workload more accurately because each referral accepted defines a certain known quantity of work.
They will be able to monitor equity of access more reliably.
They will be able to manage thresholds for access to their services e.g. higher quality data about patients who have been referred for care and their current status will enable better waiting list management.
They will be able to measure referral patterns and resource usage more accurately.
The increased communication will promote closer integration between primary and secondary services which is core to the Primary Health Care Strategy.

Other health organisations benefit from eReferrals as:

Processes and care pathways will become more consistent and will be able to be monitored against service standards.
Relevant performance data stored during and at the end of the referral lifecycle will be made available to funding organisations in a format useful to them.

What happens today
A referral occurs when one practitioner requests the services of another practitioner or service in the care or treatment of a patient.
Some typical referrals are:

General Practitioner refers patient to secondary (hospital) service to receive surgery.
Surgeon refers post-operative patient to physiotherapy to speed patient’s physical recovery.
Eye specialist refers patient to Medical specialist suspecting that cause of patient’s eyesight problems is diabetes.
Medical specialist requests services of a psychiatrist to assess mental well-being of patient.
Attendance at Emergency Department or Maternity Unit (self-referral).
Pharmacist refers patient to GP to ensure symptoms are properly diagnosed.

Most formal referral communication is on paper, for example:

Type-written letter from one practitioner to another in another service or organisation, e.g. GP letter to hospital specialist.
Referral form – patient label and associated hand-written details (often used when referring from one hospital based service to another hospital or community based service).
Electronic referral letter – from one GP to another using the Practice Management Systems (some hospitals receive these referrals electronically but print them out).

Urgent referrals for acute problems are discussed by phone or in person, e.g. one specialist to another, GP to hospital specialist. Non-urgent referrals are typically on the basis of a referral letter or completion of a standard referral form. There is also a growing tendency for communication between practitioners using newer technologies, for example e-mail, video conferencing and telemedicine.

Figure 1: A schematic representation of the flow of referral (and discharge) messages between practitioners.

A schematic representation of the flow of referral (and discharge) messages between practitioners

Areas for improvement
Problems with the current system which could be improved through eReferrals include:

Hand-written referrals are often brief and illegible.
Referrals are largely paper-based and are prone to being misfiled, sent to the wrong destination, left unattended in someone’s in-tray, and even being duplicated (because the original was ‘lost’ or because people don’t trust the system).
Uncertainty about the receipt of the referral and its progress.
Paper based referrals are inherently insecure – they can be viewed by the wrong people, and access is unable to be audited.
Data from the referral needs to be re-keyed into patient or practice management systems.
Electronic referral letters are unstructured and therefore of variable quality and completeness.
The complex information flows associated with more complex cases take a lot of time and effort to manage.

What happens next
Responsibility for implementing the Health Information Strategy for New Zealand lies with the whole health and disability sector under the leadership of HISAC. HISAC is working closely with sector representatives to prepare more detailed descriptions of current problems and practitioners’ priorities for improvements. If you would like to discuss the eReferrals initiative, please contact HISAC through enquiries@hisac.govt.nz or write to:

The Action Zone Development Leader
HISAC Office
PO Box 5013
Wellington

Relevant documents
Initial View (PDF, 223 KB)
Preliminary Scope and Approach (PDF, 845 KB)
Road Map (PDF, 49 KB)

Page last updated: 22 May 2009