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Referrals - Discussion Paper

Summary

People rely on health providers such as general practitioners to coordinate their journey and care through the health system by effectively communicating with and referring to other health providers. General practitioners rely on timely access to allied health, hospitals and specialists services and expect referral pathways to have deliverable endpoints where services are accessible and available.

There are multiple health and community services operating in Gippsland supported by a diverse and complex range of referral infrastructure, systems and platforms such as telephone based contact, secure electronic messaging, central intake, facsimile or multimodal entry points.

Successful working relationships between health services, general practice and other private providers are necessary to maximise service offerings, coordinate care and achieve the best health outcomes for people living in Gippsland.

Limited knowledge is available about the consumer and clinician perspective when accessing health service and programs in an environment where there is no uniformity with local, regional and national service directories and or ease of access to these services.

This discussion paper is intended as a starting point to explore with a broad audience of medical, social and community health professionals referral systems and the complexities facing consumers and providers in Gippsland. Melbourne East GP Network is conducting a series of interviews and surveys with stakeholders to determine options for Gippsland moving forward in the referral space. We aim to gain an understanding of the following areas; current practice, identify critical success factors, the barriers to communication between providers and the impacts on care and to the business. Our interviews will explore:

Types of referral system used by health and community services including entry point(s) where referrals are accepted

Types of referral system used by GPs when sending referrals to specialist, health and community services

The challenges and barriers for effective referral such as system and operational variance between health service, service gaps and waiting lists

An understanding of the general practitioner perspective in the context of referral

An understanding of the consumer experience and perspective in the context of self-referral, access to and availability of health services and programs.

Background

Historically systems across medical, social and community health sectors have focused on their own specific business, service and system requirements. Many older patient/client management systems have been built to operate as standalone databases where interconnectivity was not part of core functionality. The result being systems with proprietary interfaces not configured to be a part of a larger integrated system. Over the last ten years the technology environment has matured. Systems are now capable of providing solutions that leverage national eHealth services and infrastructure and are based on common business processes, standards and specifications. The medical, social and community health system environments are complex. The diverse needs of the communities using these services, combined with a diverse range of funding and reporting systems is leading to an increasingly fragmented system. In response, the service delivery landscape has evolved into a vast number of discrete silos or islands of information. There are significant barriers to effective sharing of information between service providers. Fragmentation poses real challenges for system improvement and for providers and consumers. Currently the use of electronic referral processes in Gippsland, like other regions in Victoria, is limited to specific communities. GPs tend to use multiple systems and methods to refer to specialists, allied health providers, to request and receive pathology and imaging results; community and social services use their systems; specialists and hospitals receive a mix of referral options and send correspondence and discharge letters in number of different ways. Despite pockets of use, when compared to the total number of referrals sent, there are low levels of eReferral adoption. A similar picture occurs throughout Australia. The Gippsland PHN Needs Assessment report indicates there is a level of stakeholder awareness and optimism for eHealth initiatives such as e-referrals as a means to improve communication between providers. 1 It is a widely accepted view there is a need for medical, social and community health services to be more person centred and integrated in order to deliver higher quality and more efficient care. The adoption of a strategic systems wide approach to eReferral across Gippsland provides the opportunity to:

Facilitate sector wide eReferral capacity across the Gippsland region.

Increase the quality of care through consistent use of secure eReferrals.

Obtain service level data to assist in planning and resource allocation.

Integrate individual service eReferral development using a standards based approach.

Create partnerships to develop and influence the eHealth agenda (region and State)

Progress continuous improvements for better patient/client out-comes.

Currently there are a range of Commonwealth, State and Regional initiatives that intersect directly or indirectly with eReferral activities. These initiatives are outlined in Appendix 1.

1 Gippsland PHN Needs Assessment Report - 2016

The consumer’s experience– our guiding light Consumers are challenged with difficulties and frustrations as they navigate through the health care system. A Gippsland resident, shares his recent experience below.

Michael, a middle aged, quality assurance professional recently had a fall resulting in a shoulder injury. His GP referred him to an Orthopaedic Surgeon; unfortunately the surgeon had a 4 month waiting list. Not satisfied with such a wait Michael made a series of phone calls to eventually locate a surgeon who could see him within a week. Following a shoulder operation Michael was referred post discharge to a physiotherapist with a two-month wait. Again Michael felt compelled to ring around until he located a physiotherapist who could see him earlier. As part of his follow up, Michael was referred for a shoulder x-ray to a clinic that did not x-ray shoulders. On receiving a new referral to the right x-ray clinic he arrived one hour late due to incorrect information given. Michael has returned to work, is undertaking on-going rehabilitation & is reflective of how difficult it must be for people less able than himself to navigate the health care system.

Referrals – Is there a problem? Is there an opportunity? “Patient care hinges on adequate and timely information exchange between treating doctors. Referral and reply letters are common means by which doctors exchange information pertinent to patient care. Ensuring that letters meet the needs of letter recipients saves time for clinicians and patients, reduces unnecessary repetition of diagnostic investigations, and helps to avoid patient dissatisfaction and loss of confidence in medical practitioners. Much clinician time is spent writing or dictating letters to other doctors, but the extent to which these letters contain the information needed by letter recipients is uncertain… the referral letter has been described as the most underexploited method to influence consultant attitudes and the reply letter the most neglected route of GP education” (Tattersall et al. 2002)2 A 2010 literature review of discharge, referral and admissions undertaken by the University of Tasmania revealed key elements for ensuring safe and high quality referrals:

An accurate, complete and legible referral document communicated in a timely manner

An active process of the transfer of the patient, and/or their information along with responsibility for (all or part of their care) to the healthcare provider receiving the referral and including a confirmation of their willingness to accept this role

A process that ensures the patient and carer understand and are involved in any on-going treatment/care planned during the process of referral and subsequently 3

In addition, the review revealed:

Information gaps between specialists and GPs in relation to pre referral investigations and current medication information

Information exchanged between specialists & GPs is frequently not acted upon by either party

Quality & content of a referral letter impact waiting times and triage of service

eReferral can increase patient, GP and specialist satisfaction4

2 Tattersall, M, Butow, P, Brown J, Thompson, J. Improving doctors’ letters. The Medical Journal of Australia. Med J Aust 2002, 177 (9): 516-520. 3 Cummings, E., Showell, C., Roehrer, E., Churchill, B., Turner, B., Yee, K.C., Wong, M.C., Turner, P. (2010) Discharge, Referral and Admission: A Structured Evidence-based Literature Review, eHealth Services Research Group, University of Tasmania, Australia (on behalf of the Australian Commission on Safety and Quality in Health Care, and the NSW Department of Health) 4 Cummings, E., Showell, C., Roehrer, E., Churchill, B., Turner, B., Yee, K.C., Wong, M.C., Turner, P. (2010) Discharge, Referral and Admission: A Structured Evidence-based Literature Review, eHealth Services Research Group, University of Tasmania, Australia (on behalf of the Australian Commission on Safety and Quality in Health Care, and the NSW Department of Health)

Do current practices and systems used within Gippsland support safe and high quality referrals? Do current practices cause administrative burden and duplication of work? Is frustration felt between providers? Is there an opportunity for improved communication between providers via the referral systems used?

Referral a key component to reform Services provided by medical, social and community health organisations are managed through complex systems of referrals. Any improvement to the referral process and associated workflows can result in significant efficiencies to service delivery, reduction in risk, improvements to consumer and provider experience and to health outcomes. Commonwealth and State governments have developed and are implementing a number of eHealth initiatives to support creation and transfer of electronic referrals. Technological developments have resulted in new referral platforms that are increasingly standards based and provide integration with patient/client management systems.

Benefits The major beneficiaries of an integrated eReferral system are consumers and providers. eReferral initiatives drive improvements in service business efficiencies, coordination of care and patient outcomes. One Danish study estimates widespread use of eReferrals over posted or faxed referrals can result in a 25% reduction in the cost of handling and administering for both referral senders and receivers.5 Modern eReferral systems are progressing the use of machine artificial intelligence to action items that do not need a human intervention to validate i.e. send messages when appointment created, send message if referral declined. This allows providers to allocate more time to providing their service. Full realisation of the eReferral benefits requires widespread adoption of integrated eReferral capability across all medical, social and community health sectors and geographical locations. A detailed list of the benefits derived from modern eReferral systems is located in Appendix 3. Examples of eReferral systems in use across Australia is located in Appendix 4.

Concluding Comments The medical, social and community health sectors like all industries are experiencing transformation in how they do business. eReferral is seen as one of the key initiatives that will provide significant improvements to the way information is securely shared and will ultimately improve efficiency and service delivery.

Commonwealth and State initiatives coupled with national infrastructure, the development of eReferral standards and specifications has provided an environment in which an integrated regional based eReferral solution can be developed and implemented across organisational boundaries.

Without change there is no innovation, creativity or incentive for improvement. Those who initiate change will have a better opportunity to manage change that is inevitable. William Pollard

5 A. a. Medcom,” The cost benefit of electronic patient referrals in Denmark, 2004

Definitions

Referral: Referral is the processes, tools and techniques by which a patient (and the provision of all or part of their care) is transferred between health professionals and health provider organisations to facilitate access to services and/or advice that the referring source is unable or unwilling to provide. eReferral: eReferral is a structured electronic document sent electronically between providers; content is encrypted for access only by the intended recipient; it contains consumer information formatted to enable better exchange of information and holds data elements that enable mapping between systems. The Victorian Department Health & Human Services eReferral Program requires that eReferrels be enabled by standards and specifications known as the National eReferral Reference Architecture (NeRRA) which have been developed by the Australian Digital Health Agency and where relevant Service Coordination Template Tools (SCTT) 2012.6 Further information on eReferral standards is located in Appendix 2.

6 Department of Health and Human Services, Victorian eReferral Program,Frequently asked questions. Available:

https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/victorian-ereferral-program

Appendix 1

Related initiatives

There are a range of Commonwealth, State and Regional initiatives that intersect directly or indirectly with eReferral activities. The following broad initiatives along with local initiatives need to be considered when exploring eReferral.

Victorian eReferral Program: The Victorian eReferral Program is an initiative jointly funded by

DHHS and ADHA for three Lead Reference Sites. The aim is to implement an electronic referral

system that provides end to end capability to create, send, receive, store and retrieve electronic

referrals across a selected community of practice. The project will be testing the capacity to create

a referral in one clinical management system and have it received in a different clinical

management system.

HealthPathways: HealthPathways is a web based portal with evidence-based information on the

assessment and management of common clinical conditions, including referral guidelines. The

pathways have been designed for use during consultation and are jointly developed through

collaboration between hospital and community clinicians. The pathways are written by GP clinical

editors with support from local GP’s, hospital based specialists and other subject matter experts.

Gippsland Primary Health Network is the lead agency promoting this program.

National Health Services Directory (NHSD): The National Health Services Directory is a joint

initiative of the Council of Australian Governments (COAG), that enables health professionals and

consumers to access reliable and consistent information about medical, social and community

health services. The NHSD provides information on a range of health services including allied

health, hospital and community services to support the coordination of ongoing care for patients

with chronic and complex conditions.

My Health Record: The My Health Record system is the Australian government’s digital online

health record system. The My Health record contains summaries of an individual’s health

information and allows an individual’s doctors, hospitals and other healthcare providers to view

the individual’s health information, in accordance with their access controls. Gippsland Primary

Health Network is currently supporting healthcare professional in their use of the My Health

Record.

My Aged Care: My Aged Care is an Australian Government online portal (myagedcare.gov.au) and

national phone line (1800 200 422) providing up-to-date information about aged care. The My

Aged Care assists health providers and consumers to navigate the aged care system and provide

referrals for assessment and service provision.

SupportLink: SupportLink provides a national referral and diversion gateway for police and other

emergency services to participate in early intervention. The SupportLink now enables police to

refer via a single referral gateway embedded within their systems and gives local, state and

nationally based support agencies the ability to proactively target vulnerable clients, in a seamless

and proactive manner. Police can also refer across states.

National Disability Insurance Scheme (NDIS): The NDIS supports people with a permanent and

significant disability that affects their ability to take part in everyday activities. The NDIS works with

consumers to identify supports that will help to achieve goals in many aspects of their lives.

Appendix 2

eReferral Standards

The National eHealth Transition Authority (now known as the Australian Digital Health Agency) has developed a suite of specifications and guidelines collectively known as eReferral V2.0 (referred to in previous documentation as the National eReferral reference Architecture). The eReferral V2.0 documents are designed as a standard to inform the transmission and management of a single electronic referral and the communications between senders and receivers, across the health and human service sector. Specifically:

The defining of the minimum dataset of information to be included in an eReferral document to meets the core needs of the health and human service sector referral receivers

A set of messages and notifications that can be implemented to assist in confirming a consumer’s progress through the referral process, advising of the status within the service referral process, changes to planned activities and the provision of reports to referral senders as needed

Technical interfaces and services required for the use of the National Health Services Directory (NHSD) and National Endpoint Proxy Service (NEPS).

The approach whereby forms specific to a particular service can be managed across diverse system and organisational boundaries. 7

The development of an eReferral model, the use of national infrastructure such as the NHSD and the adoption of standards has led to significant changes to the referral environment. This new environment promotes the connectedness of systems and the timely transfer of secure referrals across organisational and geographical boundaries.

7 NEHTA, Concept of Operations eReferrals 2.0. p11. Draft document

Appendix 3

Benefits

The adoption of an integrated eReferral system creates the following benefits.

Enhanced clinical governance through improved accuracy and completeness of patient information and data quality.

Integration with patient and client management systems at the point of creation.

Technology that will support existing referral workflows.

Cost efficiencies derived from economies of scale and administrative efficiencies.

Improvements to data quality and business analysis.

Supports the use of current referral guidelines at the point of care.

Reduces double handling, stored directly into patient/ client management systems

Use of a single service directory.

Better information sharing between different sources, for example between GPs, hospitals and community health services.

More time with consumers – less time resending or chasing referrals, scanning, printing, filing and posting.

Better consumer privacy through the secure electronic storage and transfer of referral information.

Reduction in receipt of inappropriate referrals (e.g. incomplete referral, sent to the incorrect service provider).

Availability of referral data provides improved service delivery planning and policy development.

eReferral audit trail.

Access to eReferral by clinicians when they need it.

Patients not lost in transition.

Both sender and receiver have more choice and control.

Decreased referrals for inappropriate services.

Appendix 4

Referral Systems

There are a multitude of eReferral systems currently in use across the State. The systems have differing levels of functionality and connectivity with patient/client management systems. The following eReferral systems, while not exhaustive, highlights the diversity of eReferral options that are available.

Argus

Further information on Argus can be found at the following address web site:

http://healthconnex.com.au/solution/argus

SeNT (Secure Electronic Network Transfer)

Further information on SeNT can be found at the following address web site:

http://www.bpacsolutions.com/

S2S

Further information on S2S can be found at the following address web site:

https://www.infoxchange.org/au

HealthLink

Further information on Healthlink can be found at the following address web site:

http://www.healthlink.net/en_AU/

Connecting Care

Further information on ConnectingCare can be found at the following address web site: https://www.connectingcare.com/

Orion Health Referral Management

Further information on Orion Health Referral Management can be found at the following address web site: https://orionhealth.com/au/

cdmNet

Further information on cdmNet can be found at the following address web site: http://precedencehealthcare.com/

GP Patient Management Systems CDA templates

Further information on GP Patient Management Systems CDA templates can be found at the following address web site: http://medicaldirector.com/ or http://www.bpsoftware.net/