Patients often fall through the cracks of our current paper-based referral system, which requires a great deal of phoning, faxing, and follow-up between family doctors and specialists. Different regions are trying to automate referrals, but Alberta is the first jurisdiction in Canada to roll out a province-wide e-referral portal.
The leading-edge solution is built on top of its existing Netcare provincial EHR system, which already has 46,000 healthcare providers in its network.
The project not only automates referrals, but it also introduces new features to improve access, such as real-time tracking and transmission of medical data. It also provides transparency about the process to patients.
Launched in July 2014, the first phase of the roll-out automates referrals for three critical areas: hip and knee arthroplasty, breast cancer, and lung cancer. “We plan to evaluate the project after a full year of implementation and will harvest the lessons learned this summer. We will then decide where the eReferral capability best fits within the AHS IT roadmap,” says Allison Bichel, executive director of access for Alberta Health Services (AHS).
The system works like many familiar travel sites, explains Bichel. GPs can logon to the e-referral portal via Netcare to conduct searches for specialists by geographic area, next available appointment, or by name.
Once selected, the system offers a standard form to capture the minimum data set required to complete a referral. Lab work and other information can be directly attached from Netcare or other sources. “We designed the eReferral form so it shouldn’t take more than three minutes to complete,” says Bichel.
GPs can track the referral through the system, much like they would track a FedEx package, as the eReferral proceeds from appointment to visit to consult letter. This enables them to close the loop and ensure the referral is completed. “Our end-goal is to also allow patients to track it too, but we haven’t launched that feature yet in this first phase,” notes Bichel.
Responsibility for confirming an eReferral booking is up to the patient and specialist, not the GP, as another important goal is to reduce the administrative burden on the referring physician. “Family doctors are frequently stuck in the middle doing a lot of admin work back and forth between the two. We did some policy work to establish roles and responsibilities in these communications. GPs can still use the system to stay on top of things without necessarily handling the booking.”
About 1,100 eReferrals have been processed through the system thus far, and the project team is still evaluating preliminary results. “About 650 were for breast cancer, and the rest were for arthroplasty and lung cancer,” says Bichel. “We had actually expected the arthroplasty category to come first because there are typically more of these referrals than others. It’s probably due to the fact that there are several major breast health centres across Alberta and there’s a very specific referral base for them.”
This unexpected finding highlights one of the chicken-and-egg challenges to uptake of the system. A breast health centre processes many cancer referrals in the course of a month, so it’s worthwhile using the new eReferral system. But family doctors may only need to do one or two arthroplasty eReferrals per month, and they’re still doing other types of referrals via fax because they aren’t in the eReferral system yet.
“Primary care providers are saying they’re more likely to use the system once more types of referrals are available,” says Bichel. “But we need a sufficient critical mass of eReferrals from them to further develop the system.”
Another issue is that family doctors are unhappy about having to exit their EMR systems to logon to another system to do a referral. “We have no choice – we have to use a separate eReferral system to bridge all the different EMR systems in the province. To tackle this, we’re looking at enhancing the system by allowing them to attach a PDF file from an EMR and send it over to Netcare instead of filling in a form.”
In preparation for future development of the eReferral system, Bichel says there’s a sister program underway called Alberta Referral Pathways, which is working on developing clinical content standards for new types of eReferrals. “There are 13 different tumor groups in the cancer world; we’ve only tackled two of them. So that could be our focus for the next wave of development.”
Both GPs and specialists need to negotiate who does what in deciding the standards for these new eReferral types. “We need to clean up these processes before we automate anything. Referral standards don’t exist now. To triage an eReferral, specialists need information from GPs. But what constitutes a minimum data set? Specialists may say they need X information, while GPs may respond that they don’t have time to provide that much information.”
Having the right information on an e-referral can increase productivity and decrease risk substantially, says Dr. Bill O’Connor, an orthopedic surgeon and VP of clinical consulting at Orion Health, a software company that provides the technology that links all the systems that use Netcare.
“When I think back to the mistakes I made when I was practicing, it was typically because we were missing important information. The more information physicians have when they’re seeing the patient, the better the results will be.”
But it would be a mistake to view eReferral systems as a temporary stop-gap measure until the nirvana of perfectly integrated health systems materializes in the future, adds O’Connor.
“There are certain things that EMRs are terrible at doing. eReferral is one of them. You don’t do your banking on your e-mail system – you use specific banking software. It’s the same thing for this.”
O’Connor says Orion is making strides in minimizing logging on and off between systems. “When we set it up, what we do is make many launches possible from within the EMR. We try to make the set-up as efficient as possible, but the reality is – and people are starting to catch on – they’re never going to be able to do everything they need to do in an EMR. They’re going to have to use other systems as well.”