Digital DI referrals improves workflow for staff, radiologists

After years of chasing an inefficient, tedious and time-consuming paper trail, diagnostic imaging (DI) departments at two Ontario hospitals are axing the fax and turning to more efficient digital workflows for requisitions and referrals.

Orillia Soldiers Memorial Hospital (OSMH) went live with Novari Health’s Medical Imaging Requisition Management (MIRM) platform in November 2023, creating an end-to-end digital process for requisition management across all medical imaging services that was kick-started with a push to adopt the province’s Ocean eReferral Network in the spring.

Halton Healthcare partnered with healthtech startup GoAutomateMD as an early adopter of the company’s healthcare solution, building a digital requisition management system from the ground up that adapts to and builds on the healthcare system’s existing processes for medical imaging.

Each implementation delivers benefits such as less data entry, less room for error, better quality data and fewer inconsistencies. Staff are gaining back valuable time, booking turnaround times are shorter and the risk of losing a requisition is gone. And most importantly, the endless paper shuffle between clerical staff, technologists and radiologists is over.

With digital requisitions replacing paper, the hospitals are also laying the groundwork to be among the first to eliminate paper faxes as part of the Ontario government’s Axing the Fax mandate laid out in its long-term plan, Your Health: A Plan for Connected and Convenient Care.

“We’ve got a working solution that allows us to ingest all of the incoming faxes and put them in ‘boxes’ to be managed by initially clerical, then technologists, then radiologists and then it goes to bookings,” said Dr. Saul Valadka, chief of Diagnostic Imaging at Halton Healthcare, describing the digital transition. “Once it’s ingested, it’s almost completely paperless.”

After more than 15 years in the finance sector, GoAutomateMD founders Jason Daly and Jag Basrai transitioned to healthcare with a unique ‘try before you buy’ model that allows hospitals to use their software for up to 60 days before deciding to go ahead with a purchase. Their solution is based on three key principles – automation, integration and flexibility – with the idea of providing out-of-the box functionality so that users get up and running quickly, but with the ability to easily customize the software as well.

The philosophy resonated with Halton Healthcare because they wanted to go paperless but were having difficulty finding a requisition management system that could support their workflow from A to Z without requiring changes to how they work.

GoAutomateMD differentiates itself in the market by aiming to digitize inefficient processes with as little disruption to existing workflow as possible. Halton Healthcare was impressed by the company’s collaborative rapid development process that uses input from front line staff as well as internal PACS and IT teams to understand current processes, identify gaps and build custom solutions that leverage and integrate with electronic medical records and other hospital information systems.

Their vision is an end-to-end digital system to handle the more than 300,000 requisitions received across Halton Healthcare’s three sites each year, including electronic referrals from Ocean as more providers transition to the provincial network. To get started, they targeted MRI requisitions coming in by fax or paper.

Using GoAutomateMD’s built-in optical character recognition and artificial intelligence (AI) capabilities, faxed requisitions are captured and digitized. Missing or illegible information is highlighted so staff can address it and once in the system, digital requisitions are reviewed by technologists, protocolled by radiologists and sent to scheduling.

“The way we like to use technology is to alleviate the tedious processes, not necessarily the overall process,” said Basrai, GoAutomateMD’s CEO. “You still need a technologist to review, you still need a radiologist to protocol, but we can help with the tedious piece.”

“This paper just flies around the hospital all day long and we get duplication of paper, lost paper – so it gets very problematic,” he added. “Hospitals are already understaffed, more and more requests are coming in on a daily basis, so these departments are getting overwhelmed.”

A key benefit of the digitized process is that instead of wasting valuable time searching through stacks of paper to find specific requests, staff can search requisitions using a digital dashboard, allowing them to promptly address inquiries from patients or referring physicians.

Inpatient requisitions originating in the computerized physician order entry (CPOE) system are also integrated in the dashboard and, according to Basrai, priority one cases are now processed within 12 hours as opposed to 24 hours.

“It improved the process overnight,” said Halton Healthcare director, Diagnostic Imaging and Laboratory Medicine, Shairoz Kherani. “We have a dashboard where we can look at the number of requisitions processed, the number being booked, it’s great.”

GoAutomateMD also built an automated process for flagging and returning incomplete requisitions. Prior to that, staff were sorting through requisitions manually as they arrived by fax, organizing them and faxing back incomplete forms, which often led to multiple attempts and long waits for responses.

“There is a huge amount of touch time that we’re no longer focusing on,” said Halton Healthcare manager, DI, Marc Cloutier, adding that booking turnaround time has halved from 20 to 10 days.
“(Staff) can move right ahead to the higher, value-added work of booking, or following up on inquiries that the radiologists need. We can start moving towards that workflow and leaving the paperwork behind.”

“What it’s doing, is housing all of the data in one place so if somebody is looking for a requisition … they can just log in and find it and they will know exactly where that requisition is,” added Kherani. “Is it in the booking pile? Has it been booked? All of these metrics we can track, and you can actually find where the bottlenecks are very quickly.”

The journey to axe the fax at OSMH in Orillia started in 2022 with a proposal to digitize referral pathways for CT and MRI but quickly expanded to all imaging modalities. Relying on a team-based approach that included the Couchiching Ontario health team and the Georgian Bay Information Network – a partnership of six regional health centres that share the same instance of Oracle/Cerner – the hospital completed its adoption of the Ocean eReferral Network by April 2023. The next step was to digitize internal referral management, working closely with Novari to configure workflow capabilities for each imaging service.

Expanding the initial scope of the project was a pivotal decision, said OSMH manager, Central Patient Scheduling, Registration, Admitting and Switchboard Jessica Gourley. “Looking back now, we can’t imagine having only a portion of our department digitized; it would be a huge change management piece,” said Gourley.

The collaborative effort to digitize referral pathways involved several hospital departments and users, including schedulers, technologists and radiologists, who worked closely with Novari. A staged implementation of MIRM was finalized earlier this year, providing an end-to-end workflow that includes receipt of electronic referrals through Ocean or by fax, integration with Cerner, internal referral management through MIRM and archiving in PACS which connects to the provincial ConnectingOntario repository.

Scheduling remains within the hospital information system, but MIRM automatically sends the request to schedule and then updates once the appointment data and time is received, with the ability to send the information on to a patient through SMS or email for confirmation. OSMH is currently working with another vendor to build the patient notification piece, said Gourley.

The new digital workflow streamlines what used to be a complex procedure with nuances between modalities. For example, CT requisitions would be scanned and sent to radiology for coding via email while MRI requisitions would be walked over in paper form. “It was just a lot of steps, a lot of inconsistencies and room for losing paper, or (instances when) somebody didn’t get an email or it went to the wrong person,” described OSMH manager, DI and Cardio, Chantel Grant.

The amount of in-house customization available in MIRM is limited, she added, but the team worked with Novari Health to get the workflow exactly to where users want, with more adjustments expected as the teams get comfortable working with the new digital workflow.

“They’re the kinds of things you don’t know until you’re working in the system – extra clicks can add up,” she explained. “There has been a bit of feedback (from users) that they don’t want to go back to paper just as long as we can make the system as efficient as they want.”

One advantage is the Novari dashboard that enables staff to log in to check the status of referrals across all medical imaging services, replacing a manual weekly data collection process with more reliable, immediate online data. Instead of relying on subjective feedback about missing or duplicate referrals, staff access consistent and standard digital records they trust to track activity accurately, with the ability to sort based on patient demographics, modality, priority and body part for reporting purposes.

Greater efficiency means workloads are reduced, said Gourley. “Unnecessary referrals don’t get downstream when they don’t need to anymore, because we can say upfront that we don’t offer that service or we can refer patients elsewhere,” she said.

“I have a handful of people on the team who are already operating at their previous efficiency or speed when it comes to scheduling, and my suspicion is that it will only improve or get better over time,” she added. “One thing I can say is that they’re not manually faxing things back anymore, typing up fax sheets or even clearing off the fax machine.”

Radiologists are benefitting from an e-protocolling feature in MIRM called RadView that provides access to all relevant information required to quickly and efficiently protocol requisitions, aligned with processes outlined by the Ontario Association of Radiologists to determine the type of exam that best suits the clinical question and patient presentation. An added advantage is that radiologists can perform the protocolling step remotely from home if hospital guidelines allow, a capability also provided in GoAutomateMD.

Both Novari MIRM and GoAutomateMD are now working to use AI capabilities to further automate the protocolling step. Basrai said his company expects to introduce an enhanced feature this year that allows for protocols to be filled out automatically and then reviewed and approved by radiologists.

“We’ve noticed a massive challenge in British Columbia right now, where they can’t find enough technologists and radiologists to do this, so they’re actually asking clerical staff to help with protocolling on simple requisitions,” said Basrai. “They’re not really trained for that, but an AI can be trained because it can see millions and millions of requisitions, and it can know and understand.”

Digital requisition management is seen as a necessary step as both OSMH and Halton Healthcare prepare for wider adoption of the Ocean eReferral Network as well as the possibility of a provincial central intake model. OSMH is already scheduling roughly 80 percent of its medical imaging requests through a central team and will be campaigning for more providers to engage with Ocean this year, said Gourley.

“We want everyone utilizing the Ocean platform for referrals,” she said. “The vision is there in the province and we’re adopting it in Orillia, and we’re really excited about it.”