Transcript Di Davis presentation

E-referrals..
Just do it!
Overview:
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•
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Our pre-electronic era
Where we are now at
Value of the generic form
Recommendations
Problems from a GP perspective
• Mailing out of date compared to how they
communicate with other external agencies
• Lack of trust in the hospital processes
→faxing and mailing
• No clear guidelines on what information to
include
• Multiple possible destinations for the same
referral type
• Delayed and dislocated notification of the
referral processing stages to the referrer
Problems from a hospital
perspective
• No way to track a referral from primary
care until entered
• Referrals being sent to specialists, to
services and to Central Referrals
• Lost referrals: how many, where did it
happen?
• Duplicate referrals (faxing and mailing)
And yet more problems…
• Faxing errors
• Multiple phone calls to services to check
up on referrals
• 100% variation in referral processing by
the services (non standard work→ errors hidden)
• Disconnect across the referral processing
workflow (errors not being feedback to source)
What about the content?
(audit MOPC referrals 2009)
• 150 GPs – at least 50 different formats
• Inconsistent inclusion of relevant clinical
information (medications/problem lists)
• 14% lacked of clarity of the question being
asked by the referrer
• 33% lacked results that would influence
prioritisation
• 14% used wizard “cut and paste” to include
more than 5 consultations
Extensive use of “wizard”
• 75%: no clear reason for referral
• 50%: did not include relevant results.
• 60-90%: of the C+P consultations contain
irrelevant material
information dumping
Risk to both patient and recipient
Summary of audit findings
The majority of referrals contain the
appropriate information
BUT
presentation of this information inconsistent
and not easily accessible to the recipient.
Main problems/risks to address
GP:
Replace paper with an electronic process
Hospital:
1.
2.
3.
4.
Faxing
Cut and paste technique
Processes applied to the referral
Presentation /accessibility of information
Going electronic
2008
• MOH call for submissions for pilots to improve
access to diagnostic services
• NPIGG support to convert paper to electronic
• Healthlink contracted to produce 3 e-forms based
on Hutt DHB e forms in use
March 2009
• Release of e-referral platform consisting of a
colorectal, breast and generic forms
Where are we up to?
• Outpatient referrals only
• 5 customised forms, all other referrals via
generic template
• Electronic processing at Central Referrals
Office
• Standardised referral processing across
services
• Printing of referral at service level beginning
After 6 months we thought…
Gains in referral quality where to be
found with customisation
The generic form had little to offer other
than providing an interim complete
platform
The generic form
What has it given us?
Overall uptake –
92% (Oct 2010) of all OPC referrals electronic
2500
2000
1500
1000
500
e-referrals
2009
2010
September
August
July
June
May
April
March
February
January
December
November
October
September
August
July
June
May
April
0
March
total referrals
GP benefits
• Faster for GP
Anecdotal reports of referral done frequently at
time of consultation
Reduction in after-hours work load
95 % completed Monday-Friday
75% of these between 8am and 5pm
“they have revolutionised my referral work”
Dr A Miller
• Provided a standard work flow
More GP benefits
• Improved security:
– real time acknowledgement of receipt
– No referral losses (in the e-system)
• Improved clarity as to what service to make
the referral to (single point of entry)
• No confusion as to where to send the
referral
And more…..
• Decision support available:
Hospital benefits from the
generic e-form
• Eliminated faxed referrals to OPC
• Improved security
• Provided ability to audit work flow
• Improved demographic data inclusion
• No more inappropriate cut and paste
• Standardised presentation
• improved accessibility of information to ALL
groups
• faster and easier to process
Hospital benefits beyond the
forms
Prompted a review of all processes
• “Single point of entry” for all referrals via central
referrals
• Standard work flow for processing all referrals
across all services (error proofing rather than error finding)
• Linked staff across services in the same work flow
• Introduced concept of errors going back to source
• Prompted a review of how we manage referrals to
out peripheral hospitals (equity across Northland)
An un-intended spin off..
Due to the standard presentation, quality
issues exposed.
stimulated interest of the hospital
clinicians in referral quality
• Unmasked errors:
– Problem list:
56% error rate
– Medication list: 46% error rate
– of these 78% were clinically significant
Patient benefits?
• Referral done closer to the decision
made to refer
• Clinical referral information:
– an initial drop, now neutral
• We don’t loose their referral
• Consistent clinical information:
positive influence on prioritisation but even
bigger benefit at time of assessment.
Medication
list
Problem
list
Paper referral
55%
55%
Generic
e-referral
100%
100%
Summary
Electronic referrals out
perform paper ones
The generic form:
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enables rapid deployment of a electronic system
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offers GPs a consistent, faster and more secure
work flow that is easily adopted
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Has benefits to all hospital staff and patients
Minimal change with significant gain
Big bang for your buck
Asking GPs to make yet
more change……
Successful customisation:
what does it take?
Time:
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To define the problem (why are we attempting this)
To quantify the size of the problem
To understand the patient flow the form will support
To review and optimise the work flow the referral will enter
Money to support:
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GP/service collaboration in designing
The form to be “built” by the IT vendor
To engage with the users as to “why” at rollout
Evaluation post roll out with evolution (continuous improvement
projects)
Skill: it’s not as easy to produce a good form as
you might think
Customised forms can add value
but…
Referral security and information
integrity are higher priorities to address.
They need a reliable electronic
platform on which they can be placed,
get this sorted first.
Recommendations
1. Introduce a generic platform “to the
front door”
2. Address problems at the GPs end
while addressing hospital processes
3.Consider customisation only once we
have a robust platform.
Undertake as part of a service review
process that includes GPs
Our future
priorities
Referral security:
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Incremental movement towards a full end to
end solution
Referral quality and function:
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Further evaluation of our current forms
Improving feedback from all users
Work with GPs/PHO to improve data quality
from PMS
Add acute referrals to the platform
Customisation only if a problem big enough is
identified as part of a service redesign
process
Acute referrals audit
(10/2010)
• Service being referred to often not clear
• Name of accepting clinician rarely present
• 45% had no medication list
• 45% had no patient problem list
• Referral not present prior to patient
presenting
Please lets stop re-inventing the
wheel….
Continuous collaborative
improvement
For any further information:
[email protected]
Wendy Carey: Surgical services OP manger
Peter Brown:
elective services project manager
Glenys Wynyard: Central referrals office manager