What was the problem that needed to be addressed?
Prior to the implementation of the eReferral system, many patients struggled to receive timely access to specialty care. Safety-net patients in San Francisco, California faced a high demand of specialty services relative to their supply, which resulted in patients waiting 11 months for routine clinic appointments for gastroenterology, 7 months for endocrinology and 10 months for nephology appointments.
What was the innovation?
An electronic referral program that originally piloted for gastroenterology services at San Francisco General Hospital (SFGH) in 2005 soon became a comprehensive and standard electronic referral and consultation system for all of San Francisco’s safety-net health system. Current primary care referring clinics include 12 Federally Qualified Health Centers, 9 teen and young adult clinics, 1 San Francisco Health Network (SFHN) women’s clinic, 1 SFHN children’s clinic, and 12 adult SFHN primary care clinics.
The web-based referral and consultation program was developed by UCSF and SFGH. The purpose of this system is to increase primary care provider (PCP) and specialist communication, decrease patient wait time to receipt of specialty expertise and avoid unnecessary in-person specialty appointments.
Essentially, a referring provider (often a patient’s primary care provider) submits an electronic referral to a specialist service. The electronic form is automatically populated with relevant information and the provider enters the reason for the consultation in a free text box. Every service has specialist reviewers who review the request and reply appropriately. The reviewer can request additional information from the referring provider, schedule a routine or urgent visit for the patient, recommend additional evaluation before scheduling a specialist visit, or give the provider and patient education without scheduling the patient for an in-person visit. All information is stored in real-time in the patient’s Electronic Medical Record (EMR). The eReferral system is embedded in the SFGH EMR so referring clinics across San Francisco must log into the SFGH EMR to use eReferral.
The graphic below depicts the workflow of the eReferral system.
Who were the key partners needed?
“Having leaders from our local Medicaid Health Plan engaged and excited was key to implementation.”
Dr. Delphine Tuot, SFGH/SFHN’s eReferral Program
To get the system approved and implemented hospital management (CFO, CMO, COO) and clinician leaders from primary care and specialty care needed to be on board and supportive of the program. In addition, many resources were needed to build and maintain the system, including a part time Medical Director, part-time Specialist Lead, full-time eReferral manager and programmer/analyst time. Primary care providers and specialists are vital end-users in the eReferral system. Providers use the electronic system to request referrals and they benefit by receiving timely specialty expertise.
What were the results?
The eReferral system “has fostered relationships across the primary care and specialty care divide. It has helped break down communication barriers and allowed recognition that all providers have similar goals in the end.”
–SFGH physician and eReferral user
The eReferral system has showed many benefits which include:
- Increased patient convenience and cost savings associated with avoiding unneeded visits
- Shorter wait times for patients requiring an in-person specialty visit
- Within the first year, the % of referrals made without a clear consultative question dropped by 75%, according to specialty services
What lessons were learned?
- Prior to the launch, it was important to understand the specific issue at hand. Creators of the system needed to determine what problem they were trying to solve.
- Understanding the primary care workflow was important once deciding to implement a new referral system. The system needed to fit within the workflow and not be a hindrance in patient care or provider usability.
- The eReferral interface needed to be updated and tailored after launch of the new system, in response to feedback from the first few user clinics.
- The key to success (enhanced delivery of specialty care) was not the technology platform per se, but rather the communication and collaboration fostered among primary care and specialty care providers.