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St li i th R f l PStreamlining the Referral Process:More Efficient Care and Improved 

Patient Experience

June 23, 2010

Alice Hm Chen, MD, MPH

Alan Glaseroff, MD

6/22/2010

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Improving the Primary Care –Specialty Care Interface

Ali H Ch MD MPHAlice Hm Chen, MD, MPH

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Primary-Specialty Care Interface

Paper, telephone, and fax based referral system

Clerical process of first referred, first scheduled

Significant inefficienciesreferral to wrong clinicunnecessary referralspremature referrals inability to discern referral questionlack of equitable triage

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SFGH Referral Network

10 independent primary care clinics

~70,000 patients

5 UCSF-staffed SFGHprimary care clinics

~30,000 patients

18% Medicare, 28% Medi-Cal, 34% Uninsured

11 San Francisco DPHprimary care clinics

~45,000 patients

Comprehensive Specialty ServicesFull-time Academic UCSF Faculty & Trainees

>500,000 ambulatory visits annually29% specialty care, 20% diagnostics

Source: SFGH Annual Report, Fiscal Year 2007-2008, available at http://www.sfdph.org/dph/files/SFGHdocs/2007-2008AnnlRptSFGH.pdf

Salaried specialistsAccess to EMR

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Development of eReferral

HIPAA compliant web-based referral systemLinked to EMR, auto-population of relevant data Free text referral questionsMandatory use for enrolled specialty clinics

New model of primary care – specialty care collaboration

Individualized review and response to each referral by designated specialist clinician (MD or NP)by designated specialist clinician (MD or NP)Iterative communication between referring and reviewing clinicians until both agree that the patient either does not need an appointment or the appointment is scheduled

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PCP submits electronic referralnot scheduled

and more

eReferral Flow

Consult reviewed electronically by specialistIncludes all relevant clinical data from EMR

Appropriate specialty referralAND

Pre-referral work-up completePCP can manage with guidance

and more information requested

PCP can manage with guidanceOR

Pre-referral work-up incomplete

Schedule Next Available Overbook

Nonurgent Urgent

EventuallyScheduled

NeverScheduled5

Impact

Elimination of illegible faxesElimination of illegible faxesDecreased wait timesAbility to triage, advise, avoidImproved specialist efficiencies

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Elimination of Illegible Faxes

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Reduction in Wait TimesMedicine Clinics: Median Wait Time for Routine New Patient

Appointments January 2007- December 2008

60

80

100

120

140

ber o

f Day

s

Cardiology (129% increase)

Pulmonary (34% decrease)

0

20

40

Jan Mar May July Sept Nov Jan Mar May July Sept Nov

Month

Num

b

Endocrine (50% decrease)

Rheumatology (29% decrease)

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Triage, Advise, Avoid January 2007 – June 2009

Average Volume

(Referrals/M

% Scheduled

Initially

% Scheduled

Initially% Initially

Not

% Scheduled After

Additional % Never %Clinic

(Referrals/Month)

Initially (Next Avail)

Initially (Overbook)

Not Scheduled

Additional Review

% Never Scheduled

% Missing

Cardiology 88 53.6 24.4 21.8 5.7 16.1 0.3

Chest 43 63.3 9.4 25.4 7.6 17.8 1.9

Endocrinology 47 26.9 14.0 58.2 17.4 40.8 0.9

Gastroenterology 229 50.0 14.2 35.4 10.1 25.3 0.4

Hematology 34 50.2 10.5 38.9 7.5 31.4 0.5

triagefunction

saving ofone visit

“permanent”savings

Liver 53 31.4 1.4 67.1 14.0 53.1 0.1

Neurology 120 83.4 7.6 8.9 4.5 4.4 0.2

Renal 40 51.5 0.8 47.4 16.0 31.4 0.3

Rheumatology 46 38.8 36.7 24.2 6.3 17.9 0.3

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Specialist Efficiencies618 surveys collected (413 medical, 205 surgical)

1B. Surgical Subspecialty Referrals

40

60

80

100

iffic

ult (

%)

1A. Medical Subspecialty Referrals

40

60

80

100

Diff

icul

t (%

)

HOW DIFFICULT WAS IT TO IDENTIFY the reason for the consultation/clinical question before interviewing and examining this patient today?

0

20

Paper-based eReferral

D *

0

20

Paper-based eReferral

D *

Percentage of specialists responding “somewhat difficult” or “very difficult.” * p-value <0.05

Hwang J, Yee HF, Chen AH, Guzman D, Bell D, Kushel MB. Journal of General Internal Medicine accepted 2010.

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Challenges to Spread

Access to common EMRAccess to common EMR

Academic environment

Specialists salaried

Primary care clinicians reported better b t kcare, but more work

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PCP Experience

Overall, how has eReferral changed clinical care for your patients?

81% response rate (298 of 368)

, g y p

Kim Y, Chen AH, Keith E, Yee HF, Kushel MB. “Not perfect, but better: primary care providers’ experiences with electronic referrals in a safety net health system.” Journal of General Internal Medicine 2009; 24(5):614-619.

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Role in Delivery Reform?

Potential for HIT to improve communication and efficiency of primary-specialty care interfacePrimary care and co-management support (versus gatekeeper role) enhances medical home model Role of specialists in reducing variations in clinical care, promoting evidence-based medicinemedicine Useful model for accountable care organizationsAddress expansion of Medicaid and anticipated specialty access crisis

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eReferral TeameReferral Steering Committee

Project Lead: Alice ChenSpecialty Lead: Hal Yee

eReferral Surgery Reviewers Breast Surgery: Kelly Ross-Manashil with Peggy KnudsonSpecialty Lead: Hal Yee

Project Coordinator: Ellen KeithEvaluation Lead: Margot KushelIT Specialists: Kjeld Molvig, Mark RistichIT Physician Liaisons: Fred Strauss, Bob BrodySurgery Lead: Julia GalletlySurgery Project Coordinator: Cindy GumpalRadiology Leads: Alex Rybkin, Nancy Omahen

eReferral EvaluationDGIM fellow, PCP Survey: Yeuen KimMedical student, Specialist Survey: Judy HwangAnalysts: David Guzman, Ryan Kimes

eReferral Medicine ReviewersCardiology: Mary Gray Endocrinology: Suneil Koliwad, Lisa MurphyG t t l /Li H l Y

ENT: Christina Herrera with Andrew MurrGeneral Surgery: Danielle Evans with Michael WestOrthopedics: Dan Bertheau. Dorothy Christian, Brenda Stengele with Ted MiclauNeurology: Sean Braden with Cheryl JayNeurosurgery/Neurotrauma: Sean Braden, Julia Galletly, Twila Lay with Geoff ManleyPlastics: Erin Fry with Scott HansonUrology: Bradley Erickson, Jeremy Meyers, Brian VoelzkePodiatry: Erika Eshoo with Sandra Martin

San Francisco Health PlanJean Fraser, Rafael Gomez, Ellen Kaiser, Alison Lum, Kelly Pfeifer

San Francisco General Hospital and Trauma CenterG O’C ll S C i R l d Pi kGastroenterology/Liver: Hal Yee

Hematology: Brad LewisPulmonary: Janet DiazRenal: Sam JamesRheumatology: John Imboden

eReferral Radiology ReviewersMRI and CT: Nancy Omahen, Alex Rybkin

eReferral Women’s Health ReviewersBreast Evaluation: Diane Carr, Mary Scheib with Judy LuceGynecology: Rebecca JacksonObstetrics: Rebecca Jackson

Gene O’Connell, Sue Currin, Roland Pickens

SF Department of Public Health Community ClinicsMichael Drennan, Lisa Johnson, Barry Zevin

San Francisco Community Clinic ConsortiumJohn Gressman, David Lown, Lisa Pratt

University of California, San FranciscoAndy Bindman, Talmadge King

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North Coast Referral NetworkHumboldt County

Alan Glaseroff MDCMO, Humboldt IPACIN June 23, 2010

Humboldt QI Progression

• Humboldt Del Norte IPA…• “Radical Incrementalism”• Focusing on functions that increase

communication, decision support, reliability, outcomes, and patient activation– Creating a virtually integrated system of care g y g y

within a culture based on autonomy• PECSYS registry comparative

reporting patient experience surveyingpublic reporting IRIS MPI 2

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Partners

• Community Health Alliance of Humboldt and Del NorteNorte

• Humboldt County Department of Public Health• Humboldt Del Norte Independent Practice

Association and Foundation for Medical Care• Mad River Community Hospital• North Coast Clinics Network• Open Door Community Health Centers• St. Joseph Health System, Humboldt County

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Problems To Be Addressed• It was difficult to contact specialty offices and

radiology departmentsgy p• Specialists had varying and ever changing

requirements for referral, including indications for referral and necessary documentation for referral

• Referring offices would fail to send documents; servicing offices would lose documents

• There were a variety ways to appoint patients and often multiple phone calls between the PCP office, the patient and the specialty office were required.

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PCP Problems To Be Addressed

• Patients were rarely able to leave the PCP office with an appointmentpp

• Once referred, PCPs often did not know if the patient had seen the specialist and if seen, the results of the visit

• If the health plan required an authorization, it tripled the amount of work necessary trying to provide the necessary information for the authorization, then trying to arrange the visit to the specialist after the authorizationarrange the visit to the specialist after the authorization was approved

• Communication and coordination was also a problem for referral to local hospitals for imaging

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Specialist Problems to be Addressed

• Many referrals were inappropriateTh t f f l d f f l• The type of referral and reason for referral were often handwritten and unreadable. These resulted in wasted visits

• PCP offices were difficult to contact; follow-up calls were not returned, and sometimes clerical staff could not easily clarify the referral orderstaff could not easily clarify the referral order

• Required chart notes, lab work and imaging studies were not sent

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Specialist Problems to be Addressed

• Practices with EMRs sent pages and pages of useless chart detailuseless chart detail

• Patients failed to meet pre-procedure requirements because they were unaware (not fasting, taking meds, etc.) causing cancellations

• Patients were difficult to contact and appointing a visit required several callsa visit required several calls

• Authorized services required clarification that the service had been authorized

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Solution: IRIS

• Partnered with vendor who developed IRIS t f C k C t H it lIRIS system for Cook County Hospital (Proximare)– Local customization

• Web-based – housed at IPA• Rules initially designed by receiving• Rules initially designed by receiving

service provider to assure buy-in

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Solution: IRIS

• PCP to Specialist referral using a rule management systemmanagement system

• ED clinician to PCP or Specialist using rules

• Referral to hospital based radiology/ancillary services using rules

• Intelligent Voice Response (IVR) for patient appointment notification, reminders and 24/7 patient query support

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Solution: IRIS

• Electronic authorization and forwarding of i tservice requests

• Patient instructions and no-show reporting• Tracking of all referrals and referral

processesResults delivered to PCPs• Results delivered to PCPs

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How IRIS is a Solution

• Clarifies referral (and eliminates illegibility)D i i t b dd d l• Decision-support embedded - rules

• No lost documents• Patients leave the referring office with legible

patient instructions specific to the exact procedure and provider they have been referred tto

• Asynchronous communication• Reduced phone calls (appts, reminder calls)

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How IRIS is a Solution

• Referring offices receive confirmation on t d t ( d h )appts and pts seen (and no shows):

“Closing the loop”• Auths forwarded automatically (work-in –

progress)• Reduces overhead• Reduces overhead• “Best practices” incorporated as a series

of questions (also in progress)

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Year One Results

• 333 users38 PCPs in 13 practices– 38 PCPs in 13 practices

– 53 specialists in 26 practices– 417 “rules”– 38 scheduling queues

• 4,800 referrals• 300 calls via IVR system• Care redesign

– Mental health, CDSMP, care transitions13

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