eReferral: Connecting Primary and Specialty Care

reprinted from Issue 8, Spring 2009 of Frontiers of Medicine (PDF)

Primary care physician Alice Chen, MD, MPH, medical director of the Adult Medical Center at San Francisco General Hospital, talking with a patient about a specialist referral.
photo credit: Noah Berger


In June 2005, the wait for the next available regular appointment with a gastroenterology specialist at San Francisco General Hospital (SFGH) was 11½ months. New appointments were booked in the order received — though sometimes referring physicians could wrangle an earlier appointment by paging and calling specialists, or by tapping personal connections.

Hal Yee, MD, PhD, chief of gastroenterology at San Francisco General Hospital reviews an eReferral received by the UCSF gastroenterology clinic. According to evaluation research conducted by Margot Kushel, MD, eReferral reduced wait times for specialty appointments by up to 81%.
photo credit: Noah Berger

To make things worse, primary care physicians would fax over referral forms that were often illegible, vague or lost by the time the patient arrived for the appointment almost a year later. Often, the specialist spent the whole appointment trying to determine why the patient was referred — further complicated by the need to engage translators, given that 40% of SFGH's patients do not speak English. Also, many patients needed essential lab tests before the specialist could make informed recommendations, requiring a follow-up appointment.

Enter Hal Yee, MD, PhD, the Rice Distinguished Professor at UCSF who was recruited in 2004 as SFGH's chief of gastroenterology for his expertise in cell biology. Within a few weeks of his arrival, he realized that one of his division's most pressing problems was the long wait for an appointment.

Yee was more accustomed to long hours in the lab than redesigning health care delivery systems. However, he brought the same inquisitive process he used in the lab to this challenge.

"You never know what problem you're going to solve when you start," says Yee.

Creating a Better Interface

He was inspired by a past mentor at UCLA, who went through all the faxed and mailed referrals by hand. "I wasn't going to do that," says Yee with a laugh. "But the idea that you would triage, communicate and educate was an important one." Motivated by the idea of marrying specialty expertise with supportive technology, Yee started talking with IT physician liaison Robert Brody and IT specialist Kjeld Molvig. Within nine months of Yee's arrival, he and his colleagues launched what was to become known as eReferral in the gastroenterology and liver clinics.

The new system helps ensure that specialists understand why patients have been referred to them, and replaces the handwritten referral forms that were often illegible or lost.

The benefits to patients have been dramatic: once 11½ months, the wait time dropped to three to four months. So far, Yee has received more than 11,000 gastroenterology eReferrals from the 500 primary care providers at SFGH, the Department of Public Health and the San Francisco Community Clinic Consortium.

Gone are the scrawled faxes and scattered voicemail messages. eReferral's database design provides a text box for a description of the patient's symptoms, and automatically pulls information such as lab test results from their electronic medical record. Yee reads every single gastroenterology eReferral, and decides the best course of action. Often he responds with follow-up questions, or requests certain tests before scheduling an appointment.

For about 25% of eReferrals, Yee determines that no appointment is needed. For example, many patients' symptoms point to Irritable Bowel Syndrome, which the referring physician can treat. This frees up more appointments for patients who truly need to see a specialist. Yee also provides helpful suggestions, and notes things to monitor that might require specialty care down the road.

Yee responds within 72 hours, and spends about four hours a week reviewing eReferrals. This compares to a half-day clinic in which he might only see six to eight patients. With eReferral, he reviews referrals for 60 to 70 patients each week — an investment which yields large dividends.

Broadening the Impact

The arrival of eReferral is especially well-timed, as budget cuts and the adverse economy strain the already fragile safety net hospital. "The specialty clinics at San Francisco General are the only reliable source of specialty care for the 72,000 uninsured adults in San Francisco," says Alice Chen, MD, MPH, medical director of the Adult Medical Center at SFGH. "Given the economy, and the number of people who have lost their health insurance, we're going to be flooded in the next year."

"The real goal is improved communication between referring and specialty providers," says Alice Chen, MD, MPH, seen here completing an eReferral.
photo credit: Noah Berger

Chen recognized eReferral's enormous potential to improve access to specialty care throughout the hospital, and with the support of $1.5 million in grants from San Francisco Health Plan, worked to bring the project to scale. Under Chen's leadership, eReferral has been implemented in 22 clinics and specialty services at SFGH, including pulmonary, endocrine, rheumatology and neurosurgery. Even though only half those clinics had funding to support their eReferral activities, faculty and staff were so enthusiastic that they volunteered their time and resources.

For each clinic that wanted to use eReferral, Chen worked to identify the right specialty reviewer. "The reviewer is not just a gatekeeper," she says. "It's about being an educator, someone who thinks about systems and wants to improve care for individual patients as well as the overall patient population, and is willing to partner with primary care providers." Chen also conducted extensive outreach to primary care providers in the community, and worked with IT lead Molvig and his team to tailor eReferral to each clinic's specific needs. She eventually hopes to bring eReferral to every SFGH clinic.

Democratizing Access to Care

Margot Kushel, MD, associate professor of medicine in residence, serves as the evaluator for the eReferral team. "Margot has been a critical part of giving this system legs," says Chen. "We've been able to provide a really robust case for how successful we are."

Kushel's research found that eReferral reduced wait times up to 81% in clinics that used it. More than seven in 10 primary care referring physicians who responded to a survey said they thought eReferral had improved clinical care. "eReferral democratizes access to specialty care and rationalizes it, so if your patient is the sickest, they are seen the soonest," says Kushel.

Specialty providers found the system helpful as well. Without eReferral, more than a quarter had difficulty identifying the reason for the patient's visit, compared to only one in 10 for those using eReferral. Surgical clinics using eReferral reported that only 14% of follow-up appointments were needed because of incomplete lab tests and other diagnostic procedures; before eReferral, that percentage was three times as great.

"Evaluation allowed us to respond to providers' concerns and tweak the system to maximize our goals," Kushel says. "It also allowed us to demonstrate the financial and manpower savings from our investment, as well as the improvement in quality." These documented outcomes helped eReferral garner funding from the Agency for Healthcare Research and Quality to study and expand eReferral. The program has also won awards, and attracted interest from the Kaiser Foundation, Bay Area counties, and as far away as the Massachusetts Department of Public Health.

Evaluation also has provided important information about what other changes would need to happen to further improve access to specialty care. Initially, clinics implementing eReferral documented a sharp drop in wait times, but reached a state of equilibrium and have not seen further wait time reductions. "We feel really confident saying, this is the limit of how many people we can see, based on our current staffing levels," says Kushel. "We are now about as efficient as we could possibly be." Kushel notes that a four month wait to see a gastroenterologist is still substantial; to reduce the wait time further would require hiring additional specialists.

Even with the current staffing levels, however, eReferral is a powerful tool for helping connect providers with each other. "Information technology is only a means to an end," says Chen. "The real goal is improved communication between referring and specialty providers. With the advances in medical knowledge, no one person can take care of everything for a patient. This is all about enhancing the transition between primary and specialty care."

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