Overview

This project at an academic medical center utilized an electronic specialty referral system integrated into the EHR to improve physician satisfaction with the referral process, to encourage patients to see specialists within the medical center, and to track patients’ appointments with specialists.

Organization Name

Brigham and Women’s Hospital

Organization Type

• Academic Medical Center
• Integrated healthcare system/network

National/Policy Context

• The number of referrals to specialty physicians in the US doubled from 1999 to 2009, with nearly 17% of primary care visits leading to referral to a specialist. 
• The referral process is fraught with challenges, including long delays, lack of access to specialists, and no database for primary care physicians to check whether their patients have seen the specialist. 

Local/Organizational Context

• 63% of providers at Brigham and Women’s Hospital were not satisfied with the specialty provider referral process. 
• Long wait times to see Brigham and Women’s Hospital specialists forced primary care physicians to refer to specialists outside of Brigham and Women’s Hospital, reducing continuity of care for patients.
• Brigham and Women’s Hospital is involved in Medicare Shared Savings programs which encourage and reward continuity of care, so fragmentation in the specialist referral system decreases revenue for the hospital. 

Patient Population Served and Payor Information

• Brigham and Women’s Hospital serves about 135,000 primary care patients.

Leadership

• Joseph P. Frolkis, MD, PhD (former Primary Care Director at BWH)
• Jeffrey O. Greenberg, MD, MBA (former associate medical director at BWH)
• Neither are at BWH anymore, and this project has since been consolidated into our Epic EHR so no ongoing management

Funding

• Health Resources and Services Administration, Houston VA; HSR&D Center for Innovations in Quality; VA Health Services Research and Development Service; VA National Center for Patient Safety; and the Agency for Health Care Research and Quality funded this intervention.

Research + Planning

• The authors used Lean principles to generate a process map of the previous specialist referral process in order to identify potential steps that could be streamlined or improved in the eReferral system. 
  • Key findings of process mapping included the following insights:
    • Referral protocols varied greatly between specialties, creating unnecessary complication for PCPs.
    • No method existed to monitor whether specialists actually saw referred primary care patients. 
    • The existing system relied heavily on interpersonal relationships between specialists and PCPs, presenting challenges to newer PCPs who lacked established professional networks.

• The authors generated buy-in from physicians by writing a “collaborative care agreement” that defined principles and norms for shared patient care between PCPs and specialists. 
• To generate buy-in from hospital leadership, the authors presented internal survey data showing that lack of clear communication and timeliness caused Brigham and Women’s Hospital PCPs to refer to non-Brigham and Women’s Hospital specialists. 

Tools or Products Developed

• eReferral: The authors contracted with the company Par8o to design an electronic referral system inside of the Electronic Health Record that primary care physicians use to refer to specialist practices. 

Training

• The team who built the eReferral system conducted a one-hour training and were present at the primary care clinics for the first days of the rollout. 
• The eReferral team performed a five-hour training for specialist clinics at one centralized location. 

Tech Involved

• eConsult/eReferral
• Electronic medical record

Team Members Involved

• Administrative Assistant
• Physicians

Workflow Steps

• When a primary care physician (PCP) decides to refer a patient to specialty care, he or she pulls up the eReferral tool inside of the EHR. 
• The PCP selects the specialty of interest and then chooses an individual specialist to whom to refer or selects the option of “next available specialist” in the clinic. 
• The PCP is prompted to provide their reasons for the referral and selects a level of urgency, from “urgent, 3 days or less” to “patient convenience”.  
• Administrators at the specialty clinic receive the referral and call the patient, typically within 1 business day, to make an appointment based on the urgency provided in the referral. 
• The referring office is notified of the scheduled appointment with the specialist. 

Budget Details

The following sources of costs were estimated by the CareZooming team:

• Cost of eReferral development and integration into the EHR.

Where We Are

The project has been completed.

Outcomes

Provider Outcomes:

• Adoption of the eReferral program: When measured in August 2014, 93% of specialist visits resulted from use of the eReferral electronic system.
• Provider satisfaction with referral process: 69% of PCPs were satisfied with the referral process as a whole after implementation of the eReferral service, compared to 21% prior to the intervention.
• Provider confidence in referral tracking: 45% of PCPs felt that they could effectively track their referred patients, up from 20% prior to eReferral implementation. 
• Perceived accessibility of specialty physicians: The percent of PCPs who believed that their patients could make appointments with specialty physicians in a timely manner increased across 5 of 10 specialties after implementation of eReferral.

Patient Outcomes

• No-show rate: The no-show rate did not change during the time in which the eReferral system was implemented.  
• New specialist visits: There was a statistically significant (p = 0.001) increase in appointments for Brigham and Women’s Hospital specialty providers within the Brigham and Women’s Hospital primary care population. 
• Timeliness of urgent referrals: Specialty providers were able to see patients referred by their PCP in an “urgent” manner in the requested 3 day window 72% of the time.

Future Outcomes

• In the future, the authors will study the effects of eReferral on healthcare spending per patient. 

Benefits

• Physicians were much more satisfied with the referral process after implementation of the new electronic tool. 
  • Improving physician experience may contribute to better patient care.
• Incorporating the referral system into the EHR, which pre-populates patient identifiers, may lead to decreased medical errors (i.e. referral sent for the incorrect patient or providers forgetting to follow through with the referral). 
• Physicians gained the ability to refer to the first available specialist in an entire specialty practice, rather than a single provider, which may contribute to shorter wait times for patients in the long term. 
• Triaging referrals into urgent and non-urgent groups may improve patient outcomes, as those who require acute attention will be more likely to be seen sooner. 

Unique Challenges

• The times between PCP referral and appointment with specialty physicians increased after implementation of the tool.
  • However, this may be due to the new eReferral feature of urgency indication and a large percentage of these indications being marked “at patient convenience”.  
• There was no reduction in referrals to specialists outside of Brigham and Women’s Hospital, although a stated goal of the project was to encourage more specialty referrals within Brigham and Women’s Hospital. 
• Total volume of referrals increased overall, potentially due to increased ease of referral, which may encourage unnecessary specialist visits and low-value care while increasing costs to the health system. 
• The authors did not track changes in patient satisfaction after the new eReferral program implementation, which omits the perspective of a key player in the process. 

Sources

• This primer was developed by the CareZooming team based on our analysis of a research article found and accessed through public sources. Authors were able to review the contents of this primer before publication, and all requested edits have been incorporated into the primer as presented above.
• Barnett ML, Mehrotra A, Frolkis JP, Spinks M, Steiger C, Hehir B, Greenberg JO, Singh H. Implementation Science Workshop: Implementation of an Electronic Referral System in a Large Academic Medical Center. J Gen Intern Med. 2016 Mar;31(3):343-52. doi: 10.1007/s11606-015-3516-y. PubMed PMID: 26556594; PubMed Central PMCID: PMC4762816.