An Interesting Paper In the New England Journal Of Medicine on eReferral.

This paper appeared a week or so ago.

eReferral — A New Model for Integrated Care

Alice Hm Chen, M.D., M.P.H., Elizabeth J. Murphy, M.D., D.Phil., and Hal F. Yee, Jr., M.D., Ph.D.

N Engl J Med 2013; 368:2450-2453June 27, 2013DOI: 10.1056/NEJMp1215594

Health care reform has generated new pressures for the U.S. health care system to take better care of more patients at lower cost. Whereas these challenges are relatively new in the fee-for-service private sector, safety-net systems have perennially had to “do more with less”; innovations in this arena have generally been prompted by clinical exigencies rather than the need to gain market share or maximize revenues.1 We believe that one such innovation — eReferral — can serve as a new model for integrating primary and specialty care.

In 2005, San Francisco General Hospital (SFGH) was grappling with a challenge familiar to safety-net organizations: providing access to specialty care.2 Because of a tremendous mismatch between supply and demand for specialty services, patients were waiting 11 months for a routine clinic appointment for gastroenterology, 10 months for nephrology, and 7 months for endocrinology. If a patient needed to be seen sooner, the referring clinician had to plead with a specialist to overschedule into already overflowing clinics. Patients would sometimes wait for months only to discover that they were in the wrong subspecialty clinic or needed further diagnostic testing, which added to delays in care.

The dual imperatives of timely access and rational triage drove the creation, implementation, and spread of our homegrown, Web-based, integrated specialty referral and consultation system, called eReferral. It uses health information technology to link primary care providers (PCPs) and specialists, with the goals of increasing access to care, improving dialogue, optimizing the efficient use of specialty resources, and enhancing primary care capacity.

Originally piloted for gastroenterology services, eReferral is now used for more than 40 services at SFGH. PCPs initiate new specialty referral requests through eReferral. The electronic form is automatically populated with relevant information about the patient and the PCP, and the reason for consultation is entered as free text, along with relevant history and exam findings.

Every service has a designated specialist provider who reviews and responds to each referral. The specialist reviewer uses the system to schedule a routine or expedited clinic visit, ask for clarification or additional information, recommend additional evaluation before scheduling a clinic visit, or provide education and management strategies without a visit (see diagram Workflow and Volume of eReferral, July 1, 2011, through June 30, 2012.). eReferral allows for iterative communication between the PCP and the specialist reviewer, with all exchanges captured in real time in the patient's electronic health record. If the patient is scheduled for an appointment, the electronic referral form — including the dialogue between PCP and specialist reviewer — is available to specialists seeing the patient in clinic.

Our PCPs and specialist reviewers quickly recognized that the system provided expeditious access to specialist expertise, with or without a visit. PCPs now use eReferral to request advice and guidance for patients who may not need a specialty clinic visit, and the system is used for virtual comanagement of certain conditions (e.g., management of subclinical hypothyroidism and evaluation of anemia). When needed, the system allows for a seamless transition to formal consultation.

The full paper (with references) is freely available here:

http://www.nejm.org/doi/full/10.1056/NEJMp1215594?query=TOC

This interactive referral model with an expert gatekeeper to ensure referrals are handled as they should be makes a great deal of sense to me and the paper certainly suggests it can be made to work well.

David.