C A L I FOR N I A H EALTH C ARE F OU NDATION Bridging the Care Gap: Using Web Technology for Patient Referrals September 2008 Bridging the Care Gap: Using Web Technology for Patient Referrals Prepared for California HealthCare Foundation by Jane Metzger and Walt Zywiak CSC September 2008 About the Authors Jane Metzger and Walt Zywiak are principal researchers at CSC’s Emerging Practices, the applied research arm of CSC’s Global HealthCare Sector. Both authors have more than 30 years experience working with, studying, and reporting about health care information systems and related issues. CSC is a global consulting, systems integration, and outsourcing company based in Falls Church, Virginia. About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information on CHCF, visit us online at www.chcf.org. ©2008 California HealthCare Foundation Contents 2 I. Introduction 4 II. Overview 6 III. Functions and Capabilities Referral Initiation Tracking and Notification Clinical Review/Approval Information Exchange Scheduling Administrative Approval and Insurance Screening Data Analysis and Reporting 1 0 IV. Technology Characteristics and Requirements IT Requirements/Hardware Interfaces Clinical Guidelines Planned Enhancements 1 2 V. Considerations in Getting Started Developing a Network Terms of Participation Rules for Clinical Review/Approval Considering the Provider Setting The Implementation Process System Interfaces Costs Homegrown Solutions 1 5 VI. Successes and Challenges 1 8 VII. Conclusion 1 9 VIII. Case Studies 2 9 Appendices: A: Developer/Vendor Contact Information B: System Overview and Feature Review I. Introduction Referring patients for follow-up or specialty care is an extremely disjointed process, regardless of whether the referring providers sit in a primary care practice, community health clinic, or a hospital emergency room. Typically, all participants —  patients, referring and receiving providers and their administrative staff, and the payer — must rely on paper, telephone calls, and faxes for communication and coordination. The result is numerous opportunities for miscommunication (or lack of communication), delays in the referral or follow-up care, and the lack of a viable method for referring providers to check on progress. For patients, the typical process means being sent off with a piece of paper and instructions about where to seek care on their own. They may not have an existing relationship with a primary care provider or specialist, and may need to contact a number of potential care sites before they find one that is taking new patients or has an appointment available within a reasonable amount time. Physicians and other clinicians who refer patients to another provider know that many of the referrals they initiate are likely to be delayed, and some may not happen at all. The resulting gaps in care are frustrating for both physicians and patients, can have serious health consequences — particularly when urgent follow-up is needed — and contribute to costs of care when patients with nowhere else to turn seek care in emergency rooms. Innovative Approaches to Arranging Care Provider organizations are increasingly turning to Web-based technology to assist them in transforming the unmanageable paper process into a more standardized program that is more likely to connect patients with the referral and follow-up care they need. Introducing automation promises to bridge the communication gap between referring and receiving providers, and in some cases, the payers underwriting the patient’s care. It can also give the providers involved information about the status of individual referrals, how well the program is working, and trends in the volumes and types of referrals being managed. For patients, the automated process can match them with a specific provider that not only has the capacity to provide care, but is also willing to accept their insurance or self-pay status. They can leave with a 2  |  C alifornia H ealth C are F oundation successful connection, and sometimes, even an actual need of follow-up care, and referrals by primary care appointment. providers for patients who need to see a specialist or ancillary care provider. When the Web-based applications include the ability to create rules that request and respond to Eight Web-based applications are described in information about individual referrals, the process this report, five of which are now commercially can be further expedited to integrate clinical rules available. All take advantage of Web technology, for appropriateness set by specialists and ensure greatly reducing the need to purchase additional that prior diagnostic work-ups are in place. This user devices for participating care sites. The systems new capability provides the ability to transform the are administered by an application service provider, process by ensuring that referrals are appropriate, which saves the purchasing organization from the as well as by communicating patient-specific technical challenge and expense of hosting the information between referring and receiving software on its own servers. providers. In addition to an overview of the software systems, All in all, the goal is to have a more orderly, reliable, this report includes an explanation of their functions, and successful referral process. characteristics, and technology requirements; considerations for organizations that may wish To introduce other provider organizations to these to implement them; a summary of success and possibilities, the California HealthCare Foundation challenges experienced by early adopters; and four commissioned research to identify and describe the case studies from the field. Web-based applications being used by all types of providers nationwide. Because this product niche is Further information about vendors and developers quite new, identifying all of the participating users and the capabilities of the identified software proved challenging. The research team used Web solutions is provided in the appendices. research and outreach to many associations and individuals to identify organizations with operating programs and the vendors who have developed and, in most cases, sell Web-based applications designed for this purpose. However, given that this area has yet to evolve into a clearly defined segment of the software marketplace, the authors believe that while the identified products are illustrative, the portrait is probably not complete. The purpose of the report that follows is to provide an overview of the Web-based applications for arranging referral and follow-up care and the types of practice sites they support. The results suggest that while this innovation has the potential for broad adoption, the initial steps have come from public health systems and other safety-net providers. These organizations are targeting two important types of patient hand-offs that often fail to occur: referrals by emergency departments for patients in Bridging the Care Gap: Using Web Technology for Patient Referrals   |  3 II. Overview Each of the Web-based referral systems reviewed for this report is designed to more effectively link patients who need specialty, follow-up, and primary care with appropriate care sites and providers. This effort includes supplying the referring providers with tools they can use to: K Initiate the referral while the patient is being seen; K Track and review the referral process; K Identify and control referrals by factors such as payer and plan, reason for referral, work-up, schedule openings, and other conditions; K Facilitate communication with the receiving provider about the referral, and vice-versa; and K Help patients understand and manage their referrals, using methods such as printed hand-outs at the point of referral, letter generators, and reminder notices to contact the patient. Types of Referrals and Settings The programs identified in this study were initially developed to address one or both of two referral situations: K Emergency room providers referring patients to primary care clinics; and K Primary care providers referring patients to a specialist physician or ancillary care provider (such as an imaging center). Certainly, other referral situations — such as an attending physician referring a patient to primary care upon discharge from the hospital, or an emergency-room physician referring a patient to a specialist — could also benefit from a more organized approach to ensure access to follow-up care. However, although vendors and developers of Web-based applications mentioned such referral scenarios and their systems are able to facilitate them, examples from the field were not provided, and interviews and case studies could not be performed. 4  |  C alifornia H ealth C are F oundation Applications Identified essentially closed systems where public providers Eight different Web-based software applications function as the primary source of specialty care for are discussed in this report. Six of the applications safety-net patients. In contrast, the Eceptionist and were initially developed to facilitate referral from ERP/ERS systems are designed for coordination primary care to specialty care. Of these, one was between private primary and specialty care providers. primarily developed for a telemedicine network Lastly, the two emergency department referral (Eceptionist) and another has since expanded to systems are used to manage referrals between include emergency department, hospital, or specialty community hospitals and private community clinics referral back to the primary care provider (Cook or independent primary care providers. County IRIS). Two applications were designed to accommodate referral from the emergency Not surprisingly, distinctions in both the care setting department to primary care providers (My Health and provider system characteristics often highlight Direct, ER Connect). differences in how the applications function and the way they were designed. Four of the reviewed Additionally, the reviewed applications represent systems are homegrown solutions developed to meet a variety of provider systems. Four programs (San the needs of specific provider organizations; one is Francisco eReferral, Los Angeles RPS, Cook County now available as a commercial product. The other IRIS, Santa Clara Access Express) primarily facilitate four were purchased from commercial vendors and referral from both public and nonprofit community modified as needed. clinics into public specialty clinics. These are Table 1. Applications and Products P rod uct Vendor or Develop er Re fe rral Sit uation P rovid e r Conne ctio n eReferral Developed by San Francisco General Primary care provider to Public and community clinics Hospital specialist to public specialty clinics RPS Developed by Los Angeles County Primary care provider/specialist Public and community clinics Department of Health Services to specialist to public specialty clinics IRIS Developed for Cook County Health Primary care provider to Public and community clinics and Hospitals System by Proximare specialist/ancillary to public specialty clinics Health, Inc., now offered by Proximare Emergency department/hospital Health, Inc. to primary care provider Access Express Customized for Santa Clara Valley Health Primary care provider to Public and community clinics and Hospital System by Health Access specialist to public specialty clinics Solutions, now offered by Health Access Solutions Eceptionist Eceptionist, Inc. Primary care provider to Developed for telemedicine; specialist/ancillary now being used by large Primary care provider to health systems and networks telemedicine provider ERP/ERS inetMD, Inc. Primary care provider to Community clinic to specialist independent specialists ER Connect Developed for Orange County Health Care Emergency department to Private hospitals to Clinic Connect Agency by NetChemistry, Inc. primary care provider independent primary care providers and community clinics My Health Global Health Direct, Inc. Emergency department to Private hospitals to Direct primary care provider community clinics Bridging the Care Gap: Using Web Technology for Patient Referrals   |  5 III. Functions and Capabilities This chapter reviews the functions and capabilities available in Web-based solutions for provider organizations. Some are common to all of the applications, others are defined by the variations in program design they support. Details concerning the functions and capabilities in the eight identified applications are provided in Appendix B. Referral Initiation In all eight systems, a user initiates the referral by completing an online Web-based request form at the point of care. New patients must be registered, a step requiring entry of a small number of data elements (demographics and insurance information). Most vendors reported that the application can support downloading patient demographics from the local registration or billing system, but manual entry remains the most common method. The applications reviewed in this report vary in the extent to which they allow referring providers to initiate a referral based on defined criteria. Most limit the available search terms to basic categories such as type of service or diagnosis. In some systems, the pick list can be further filtered according to the patient’s insurance type or plan, home Zip code, access to public transportation, and any gender or language preference for their health care providers. The criteria are set for each participating receiving site, enabling the referral process to operate according to these terms of participation. The desirable mix of filtering criteria depends upon the type of program and the setting. Within a single organization that provides both primary and specialty care under the same corporate umbrella or a community network of providers all committed to caring for any patient regardless of their insurance status, insurance type is not needed for matching. In applications designed to support appointment scheduling, search criteria also include an open appointment slot for the type of service being requested. The importance of match criteria such as distance from home and accessibility via public transportation depends on location and the patient population served. 6  |  C alifornia H ealth C are F oundation Tracking and Notification information for the receiving site, and sometimes All of the eight systems create a referral record directions, public transportation options, and for each service request and provide some sort of instructions relating to the requested service. One notification at the receiving site. In addition, all system includes the option to notify patients of are designed so that staff members at the receiving booked appointments via interactive voice response. sites can be system users, reviewing incoming referrals electronically, sending and receiving referral- Clinical Review/Approval related messages and notifications, and viewing Receiving providers (specialists in particular) typically referral status information. However, the systems review referrals before scheduling an appointment to are also designed to communicate with some or ensure that the requested type of service or provider all receiving sites via one-way fax or mailed paper is appropriate and that all the relevant information copies of referrals. Providing this more basic option will be available when the patient is seen. The (which replicates the traditional manual process) is Web-based applications described in this report offer important to permit participation of receiving sites different approaches to automating clinical review not able or willing to invest in the infrastructure and approval in the referral process, and broadly necessary for online notification. reflect the unique provider culture and organizational arrangements that characterize their systems. In all All of the products permit users to view the status of cases, however, referral review and approval processes any particular referral, although the scope of tracking are standardized. depends upon the information captured during the referral process. At the most basic level, the system For example, whereas the two referral systems that records the time and date that each referral request link emergency departments with primary care was initiated. Depending upon the application and providers (My Health Direct, ER Connect) do not how many other referral-related tasks it automates, include clinical review requirements, each of the referrals can be tracked according to: six specialty referral systems have defined review processes. Four of these systems rely on manual K Appointment booked; review of referral requests by receiving providers, K Appointment kept (or missed); who can then select from a menu of options to accept, deny, or request additional information for K Authorization obtained; and referrals. K Report back to referring provider received. Two applications (Santa Clara Access Express, Cook For staff assigned to monitor referrals so that County IRIS) have rules-based auto-approval, corrective action can remedy delays and roadblocks, though they differ greatly in design. The IRIS system the systems also provide lists of referrals in delayed incorporates complex branching logic into the status (i.e., appointments missed, referral not questions and answers used to capture information, completed within 30 days, etc.). Some of the whereas Access Express requires referring providers applications also notify participating service sites to respond to a uniform and limited number of when the status of a referral has changed via an alert questions for each specialty. The solutions permitting sent to the system inbox, sometimes with a parallel rules-based auto-approval also give referring electronic mail notice to an external email system. providers the option to appeal denials and route the record to an electronic inbox where it is reviewed Patient notification is accomplished by printing by a team or designated person of authority in the personalized instructions that can include an specialty practice. appointment date and time or where to call, contact Bridging the Care Gap: Using Web Technology for Patient Referrals   |  7 In all the applications, the clinical review and Table 2. ore and Variable Functions of Web-based C approval requirements were designed to respond to Referral Systems the unique nature of the referral network and under Functio n Core Variable the leadership of participating clinicians. Clinical • Review/approval • Manual vs. rules- Review/ process standardized based review/ Approval in each setting approval Information Exchange • Approval/denial/ As with the clinical review/approval process, all eight redirect options applications support standardized requirements and • Provider communication/ processes for referral submission and information feedback tools on exchange. All allow referring providers to submit initiated referrals free-text comments about the diagnosis or procedure Information • Receiving provider • Format and level for which the patient is being referred as part of the Exchange can request more of information information/work-up sent with referrals referral request. A few also allow other pertinent • Information submission • Link to EHR patient information, such as lab, medication, and requirements • Format of claim data, to be linked to the referral. standardized in each progress note setting (scanned, pasted, • Referring providers can downloaded from Each of the Web-based systems is designed to add free-text notes EHR) facilitate a feedback loop between referring and receiving providers. In addition to responding to referrals with additional information or work-up requests and the posting of acceptance/denial Scheduling would be accomplished more easily if the decisions, most of the systems allow the referring referral management applications were electronically provider to attach and electronically transmit linked to the local scheduling system, allowing users free-text notes or document files (notes, images, test to book appointments directly. This enhancement results) scanned, pasted, or downloaded from an is on the high-priority wish list for one of the eight electronic health record (EHR). systems, but none now operate in this way. Scheduling Administrative Approval and Though the systems reviewed here have contributed Insurance Screening to more timely and transparent referral approvals, The eight systems support a number of approaches most do not yet offer real-time scheduling. More to integrating insurance/payer screening directly commonly, they support preliminary steps toward into the referral process, generally based on the arranging care by facilitating referral approval, requirements of participating providers. The most identifying the appropriate care site or provider, basic matches each patient request with a receiving notifying both parties to the match, and indicating provider who will take the patient’s type of insurance that one or the other is to initiate a telephone call to without involving the payer directly. In all other book the appointment. Two of the eight applications respects, the receiving site is then responsible for allow for real-time scheduling using a “stand-in” determining patient eligibility, coverage, and, if approach (discussed in the following chapter). needed, authorization of the referral. At the other Receiving care sites can post available appointment end of the range, some applications can route slots in the application for direct booking from the authorization requests electronically to the payer referral site. This makes it possible for patients to and allow posting of authorization status (by the leave with a booked appointment. insurer or someone in the provider site who obtains authorizations via telephone) so that it can be used as a way to track referrals. 8  |  C alifornia H ealth C are F oundation Data Analysis and Reporting The ability to generate referral reports is one of the most valued benefits of initiating a Web-based referral system. Each of the applications identified here has a library of available standard reports that users can request for a particular date range and other standard variables (e.g., referral type, receiving provider type). All but two also offer a report writer that provides more flexibility to tailor reports addressing a particular management concern. (The two currently lacking this capability have included it in their enhancement plans.) Bridging the Care Gap: Using Web Technology for Patient Referrals   |  9 IV. echnology Characteristics and T Requirements All of the applications reviewed in this report were developed to take advantage of Web technology. As a result, the vendors (or sponsoring agencies in the case of homegrown systems) offer the products as an application service provider (ASP), meaning that the vendor or sponsor provides and maintains the software on its own servers. All of the vendors are also willing to sell the application and turn hosting over to the customer, although remote hosting remains the prevailing model. IT Requirements/Hardware Because the applications are Web-based, IT requirements for referral and receiving sites are minimal. Sites where referrals are initiated need one or more computers with Internet access (preferably high-speed), and at least one printer. More computer workstations are required when physicians and other providers interact with the system directly to initiate and track referrals. If the referral process includes attaching information scanned from paper medical records, referring sites also need one or more scanners. In sites that receive referred patients, workstations and printers are likewise needed if staff members manage the application online —  that is, perform tasks such as posting available appointments or reviewing/approving incoming referral requests. In a number of the systems reviewed for this report, however, the only requirement for receiving providers is a fax machine. Interfaces Several vendors claim that their applications can support interfaces with external applications used in customer sites. However, with the exception of simple registration interfaces for downloading minimal patient demographics, customers operate the identified system in isolation. The difficulty of creating interfaces with legacy systems from disinterested vendors is often cited as the major barrier. Registration The most common interface among the eight systems reviewed for this report links the referral software to patient registration systems or modules. The interface both helps identify the patient as an eligible care recipient and reduces user workload by automatically 10  |  C alifornia H ealth C are F oundation downloading demographic data (such as address, Clinical Guidelines telephone number, etc.) that otherwise must be Direct access to clinical guideline content (such entered manually. It is possible to submit referrals as Milliman and other commercial products) is without this interface, however doing so addresses available with one system. The vendor provides a one of the biggest user complaints: having to re-enter link that users can employ during referral record data that already exists in electronic form. creation and review. Commercial guidelines require a separate license fee. Scheduling Interfaces Another useful interface that has yet to be Other systems include options to insert specific incorporated into most Web-based applications is guideline content (developed by customer direct access to scheduling systems for real-time organizations) into modules such as rules-based booking of patient referral appointments by either questions and answers, and work-up questionnaires the referring or receiving provider. Except for (for example, “Is the patient currently using a one product that also incorporates a scheduling corticosteroid inhaler?”). application, no systems reviewed for this study are being used with a scheduling interface. Planned Enhancements The most common enhancements on developers’ It is important to note that the scheduling provided drawing boards are new interfaces, including those by applications described in this report refers for: to “second-hand” or “stand-in” scheduling, in K Demographic data downloads; which receiving providers manually post available appointment blocks, and then enter those that are K Direct appointing booking; filled back into their scheduling systems. K System event downloads (such as kept and no-show appointments); EMR/Patient Record Interfaces Two types of EMR/patient record interfaces were K Direct access to EMRs for patient record identified in the programs and software applications reporting; and reviewed for this study: K Direct access from EMRs to facilitate the creation K One program includes a link to the hospital of referral records. clinical information system used to report progress notes. It is used by referring providers Other planned responses to user requests include (who are notified when the note is available) to report writers (to enhance standard reports and review specialist consult notes and reports. limited ad-hoc reporting tools), rules-based approval K with branching-logic questions, and options to The other is an option available with one develop custom rules-based questions by payer and application to provide direct access to the plan. program from within ambulatory EMR systems, such as during order entry or charting. It is not being used by any providers examined for this study. Bridging the Care Gap: Using Web Technology for Patient Referrals   |  11 V. onsiderations in Getting Started C The research for this report highlighted a number of important considerations for the development and implementation of Web-based referral systems: K Most are designed to formalize existing provider relationships, rather than develop new affiliations; K It is important that the systems be configured to help providers define and manage the terms of their participation according to patient volume, payer type, processes to ensure clinical appropriateness, and other considerations; K Developing new clinical review/approval processes requires clinician buy-in and should reflect local perspectives and system characteristics; and K Implementation is easy; however, developing provider networks, terms of participation, and clinical review/approval processes requires time and commitment. Developing a Network A key element of all eight Web-based referral programs was agreement about the roles to be played by referring and receiving sites and providers. In all of the examples identified, most if not all participants were part of the public/private safety net or had a long-standing history of working together on behalf of a shared patient population. The simplest path for other organizations considering a more formalized referral relationship is to start with the network of providers that is already closely affiliated. To establish similar programs where such close affiliations and history of working together do not exist, the necessary partnerships involve: K Agreements from primary care clinics and practices to provide primary care to patients diverted from emergency departments or referred for follow-up care by an emergency department; and K Agreements from specialist and ancillary providers to provide referral care to patients referred from primary care clinics and practices. 12  |  C alifornia H ealth C are F oundation Terms of Participation Considering the Provider Setting For the Web-referral system users reviewed for this An important consideration is the provider setting report, the challenge was less about finding providers in which the system is being implemented. Not willing to receive referred patients than establishing surprisingly, in those where receiving providers all the details about the flow and pre-conditions: how fall within the same corporate umbrella (e.g., public many patients, what types of insurance, and how specialty clinics), there are more opportunities to to ensure clinical appropriateness. Control of all specifically define shared clinical guidelines and of these aspects by the receiving sites and clinical approval criteria. In an open referral setting, however, departments proved to be essential, even among the systems are more likely to emphasize clear closely affiliated participants. processes, appropriate availability of information, and provider control over terms of participation. For example, when asked to make a designated portion of the clinic or practice schedule available The Implementation Process to referring providers for direct booking of Except for the work required to establish clinical appointments, many are reluctant to participate. guidelines and rules, implementation was reported to Doing so requires not only blocking the slots in be simple and fairly straightforward. the local scheduling system, but also updating the local schedule when a referring site books an The use of Web-based applications simplified appointment. To navigate this problem, successful ensuring user access. Several interviewees reported partnerships in the identified programs found it that all participating sites already had computer crucial to leave control in the hands of the receiving workstations with broadband access. Others site, allowing it to post appointments and make successfully funded necessary purchases with grants adjustments as necessary in the referral system. or temporarily instituted paper-based referrals where providers did not have the ability to enter referrals Rules for Clinical Review/Approval directly. In persuading specialists to participate, several organizations found another key element was the The fact that all commercial systems were offered ability to replace the traditional manual review with as an ASP further simplified the implementations. questions geared to gaining sufficient background Vendors typically performed both initial application information to determine the clinical appropriateness configuration and set-up, support that largely of a given referral, and to deny or defer referrals obviates the need for IT-savvy staff in the customer when clinical appropriateness could not be sites. established. Building this into the program required a prolonged process to establish consensus regarding System Interfaces the guidelines to be used, as well as a software The other technical consideration is the ability application that could incorporate them into the to interface with external systems. For obtaining referral request transaction. In one organization, it patient demographic and insurance information at took a full year to develop, review, and gain approval the front end of the referral process, the desirable for the initial set of rules. These addressed the ten interfaces are with registration, practice management, most common diagnoses/reasons for referral for each and possibly EHR applications. Interfaces with specialty department, and limited the considerations scheduling systems allow receipt of information to be employed in approving or denying each type of updates concerning booked and kept appointments referral to no more than three. (and potentially, direct scheduling). The ability to attach electronic clinical documentation from an EHR would also be desirable. Interfaces add Bridging the Care Gap: Using Web Technology for Patient Referrals   |  13 technical complexity and cost; they are limited in ensure that sufficient Web-enabled workstations, the identified referral programs to fairly simple printers, and faxes are available in user sites. links for downloading information such as a patient Interviewees from the identified programs all address and telephone number. One program reported that emergency departments, physician also includes an interface to the enterprise patient practices, and clinics almost always have these care documentation system to permit referring devices in place for other uses. One program, providers to view consultation reports and other however, needed a sufficient quantity of additional communications from specialists. user devices that external grant funding was arranged to cover the cost. Costs Costs for purchasing, implementing, and operating Implementation and Vendor Support the systems vary according to multiple factors, Costs for vendor support are associated with each including whether the system is homegrown or of the implementation efforts discussed above. purchased and whether it is hosted remotely. Associated vendor charges are typically bundled into fees for one-time installation support. Application Licensing, Subscription, and Maintenance Other Implementation Costs All of the commercial systems identified in this Provider organizations implementing one of the report are offered in the ASP model, in which identified Web-based applications incur additional the customer avoids both high upfront costs costs, primarily in staff resources devoted to set-up for purchase, implementation, and technology and training. Dedicated staff include a system infrastructure, as well as the risk of a prolonged administrator who is also heavily involved in all implementation process. These characteristics make of the initial implementation activities such as a big difference to organizations wishing to offer a functionality, user access assignment, and typically, more manageable and effective referral process to arranging and delivering training. Long-term tasks their providers and patients. This is particularly true for this staff role are less time-consuming, but for organizations in the safety net, which appear to include managing system upgrades and problem be most engaged in this innovation so far. solving. The vendors of these systems charge a straight Clinicians from multiple departments and disciplines subscription fee or a one-time licensing or must also devote significant time and effort to installation fee, plus subscription and/or the introduction of a Web-based referral system, maintenance costs (see Appendix B for details). particularly when clinical rules are being developed Straight subscription fees are yearly charges for the for specialty referrals. entire network; subscriptions used in conjunction with licensing and other one-time fees are based Homegrown Solutions on volume metrics such as number of users. The In terms of functions, the most complex solutions common industry maintenance fee is 18 percent of identified for this report were custom-developed the license purchase price. Some vendors also include for specific provider organizations or communities. fees for special services, such as assistance with (Two of these are now also commercially available, clinical rules development. and dissemination plans are underway for the others.) Although specific cost information is not Hardware available, it is presumed they were substantial. In at Since the typical approach to application hosting is least two cases, significant grant funding helped to the ASP model, provider organizations need only underwrite the development. 14  |  C alifornia H ealth C are F oundation VI. Successes and Challenges Sponsors of the referral programs reviewed in this report — public health systems and safety-net providers — have limited resources for research. In addition, the software applications themselves are relatively new. As a result, formal impact studies have not been undertaken, and information on successes and challenges is mostly anecdotal. However, the anecdotal evidence obtained from the case studies summarized here suggests some initial progress in meeting program goals. This chapter describes those successes from the perspectives of the program administrators, referring providers, and receiving providers. The challenges identified are more generic and are discussed from a single point of view — that of overall program management. Program Sponsors Improved data collection and reporting capability was a common benefit of the Web-based referral applications highlighted by program administrators. Several reported that prior to implementation of the referral applications, services were run without the accurate information on referral volumes, patient characteristics, and other information needed to understand the nature or quality of referral patterns, assess capacity shortages, or allocate resources. Generally, the only information source was paper-based logs, which were often incomplete, unreliable, and in some cases, rarely used. Administrators reported that immediate access to reliable, up-to-date information has placed them in a much stronger position to identify and understand their referral patterns and target improvements in the referral process; use data to identify mismatches between demand and supply and justify requests for more resources; and track and demonstrate improved processes, efficiencies, and outcomes resulting from the program. As an example, the Santa Clara Valley Health and Hospital System identified previously unrecognized outlier utilization among patients and departments. These discoveries allowed them to target improvements in referral and scheduling practices that had been operating incorrectly for several years. Additionally, the San Francisco eReferral program has been able to track the number of referral requests to participating specialties over time, highlight the proportion of booked, over-booked and denied requests, and Bridging the Care Gap: Using Web Technology for Patient Referrals   |  15 identify a number of issues related to referral patterns issued until long after the referral is completed. and processes. La Clinica de Familia uses its program to assign a nurse, medical assistant, or other staff to each A few of the program administrators highlighted referral as a way to ensure that the visits occur. It preliminary improvements in appropriate utilization. also provides a new source of online care history. Some examples include: Receiving Providers K As described in the case study from Aurora Receiving providers benefit in a number of ways. Sinai Medical Center, the implementation of They can control the flow of referrals by specifying the My Health Direct system in the emergency services, patient insurance, and, in some program department has resulted in a 45 percent decrease models, patient volumes accepted. This not only in emergency room visits, and 92 percent of affords local control, but also leads to a more orderly, patients referred to a primary care provider have predictable process. not returned to the emergency department for routine medical treatment. All of the identified applications also provide a K The Orange County Health Care Association legible and complete referral request, either by fax or reports that referring emergency department the software itself. The receiving provider may see: patients to assigned home centers for follow-up K Information verifying patient insurance eligibility care has resulted in an increase in community and insurance authorization (including the health center utilization. authorization number); K At the Cook County Health and Hospitals K Information about any special needs the patient System, where an estimated at 20 to 25 percent may have, such as preferred language and of total referrals were previously sent to the wrong interpreter; department or provider specialty, a Web-based system is credited with reducing misdirected K Pre-review according to established clinical referrals. appropriateness criteria, including completion of work-up testing and other interventions; Referring Providers K The ability to send and receive electronic messages For referring providers, the greatest reported value about specific patients in a secure manner; and is the assurance that the patient is more likely to receive needed care. Even when the patient leaves K Relevant imaging results and other medical record without a specific appointment, an appropriate information appended by the referring provider. provider has been identified and the process leading to an appointment has been set in motion. In one case, the improved process was reported to have freed up capacity for specialty care when fewer Other benefits include: repeat visits were needed, because patients arrived with completed work-ups and the right information K Communication with receiving providers. available the first time. Specialists at another program This includes the option to send notes to clarify also remarked that communication tools — their the reason for referral or relay something specific ability to send referring providers messages with about the patient. Many systems also offer the questions, requests for further information, and option to review progress notes from the referral reasons why a request is being denied — is having visit, which helps to facilitate follow-up care. a noticeable effect on the quality of initial requests. K Tracking. Every system includes tools for That is, referring providers have learned to try tracking the referral from the time the request is important initial steps before requesting referrals, 16  |  C alifornia H ealth C are F oundation order appropriate work-ups, and include comments who do not directly enter data; the other singled and attachments that facilitate both the approval and out the continuing burden imposed by frequent priority assignment of the referral request. staff turnover. Ensuring that all users attend training is also challenging. The approach at one Challenges site is to require training before users are assigned Both vendors and leaders of programs using a username and password. Web-based solutions report that challenges remain. K Developing rules. Rules-based approval Areas where the referral process could still be modules are appealing for delivery of predictable, improved include: automatic, and timely approval/denial judgments K Entry of patient demographics. As noted earlier about specialty referrals. However, developing the in this report, users of systems without interfaces necessary questions, answers, and criteria — and for downloading a patient’s address, telephone reaching consensus about them — requires number, and other demographic information significant time from the specialists. Once the place a high priority on replacing this manual task system is live, the rules also require careful with downloads from other systems. management to control new releases, keep version records, and provide a process for modification K Scheduling. Ideally, every patient referred for recommendation, review, and approval. follow-up or specialty care would leave with an appointment in hand, but few programs are K Event logging. Tracking the status of individual structured to make that possible. Accomplishing referrals requires that each step in the process this requires a very close working relationship is recorded in the system. Accomplishing this between the referring and receiving sites and is easiest at the initial stages, when requests overcoming a widely held reluctance to relinquish are initiated, approved, or denied. The greater control over even a portion of the schedule. In challenge is getting users to log follow-up cases where the circumstances are right, interfaces events, such as when an appointment is booked, with scheduling systems would be much rescheduled, kept, or missed. One vendor better than the current approach to “stand-in” planning a scheduling system interface intends scheduling. None of the systems examined now to capture schedule status updates, as well as to offer such links, but several are planning to permit direct appointment booking. Some sites develop them in the future. report that receiving providers do not reliably post consult notes. Of the eight programs described K Physician data entry. Several programs, in this report, two help enforce progress note particularly those that use rules-based clinical posting by sending automatic reminder messages approval modules, are designed with questions to receiving providers. targeted at physicians, and therefore provide better results when physicians interact with the system to provide the responses. However, physicians at some sites are reluctant to add this task to their workload, while others lack adequate workstation access. Leaders in several programs identified in this report continue to work on this issue. K Training. Training was listed as a major challenge by staff from two sites: one cited the need to overcome the problems resulting from physicians Bridging the Care Gap: Using Web Technology for Patient Referrals   |  17 VII. Conclusion Early adopters of Web-based solutions to facilitate referral and follow-up care all report good progress — both in reducing the barriers for patients and establishing a more orderly and manageable process for managing the complicated task of handing-off patients. Both provider organizations and vendors are gaining more experience and identifying ways to improve both the referral process and the technology solutions. Awareness of both the magnitude of the care gap discussed in this report and the implications for cost of care and health outcomes is clearly increasing. A number of efforts are underway in California and the nation to facilitate more efficient specialty referral and redirect patient care from the emergency department to more appropriate settings. Vendors identified in the study report a growing number of inquiries, and an increasing number of homegrown solutions are becoming available as products. All of this activity points to the growing interest in this product area and the increasing likelihood that it will become a recognized part of the vendor marketplace and the clinical landscape. 18  |  C alifornia H ealth C are F oundation VIII. Case Studies Four case studies have been assembled to illustrate not only how the use of a Web-based application enabled different provider organizations and communities to set up an improved referral process, but also the operational challenges that the system addressed. The cases profiled range from relatively small providers with a limited number of referrals to more complex organizations serving large patient populations. Table 3. Case Study Participants S oftware Orga niz ation P rogram M od e l A pp licatio n Aurora Sinai Medical Center, Milwaukee, Wisconsin • Emergency department in • Post-triage My Health community hospital • Follow-up care Direct • Emergency department to primary care physician La Clinica de Familia, Las Cruces, New Mexico • 9 community health clinics • Primary care physician to inetMD specialist/ancillary Santa Clara Valley Health and Hospital System, California • County health system • Primary care physician to Health Access • 10 primary care clinics specialist Solutions • 25 community health centers Cook County Health and Hospitals System, Illinois • Cook County Health and • Primary care physician to IRIS Hospitals System specialist • 3 hospitals • Emergency department • 16 community health centers and specialty clinics to primary care provider Aurora Sinai Medical Center – Emergency Department Setting Aurora Sinai Medical Center (Aurora Sinai) is a 195-bed, full-service community hospital in Milwaukee, Wisconsin, that is part of Aurora Health Care — the largest integrated health system in southeastern Wisconsin. Bridging the Care Gap: Using Web Technology for Patient Referrals   |  19 Value Proposition Several types of clinics are available for referrals: Aurora Sinai’s motivation for acquiring My federally qualified health centers (FQHCs), Health Direct was to help staff find and schedule independent community-based providers, and several on-the-spot appointments for patients requesting Aurora ambulatory clinics. Aurora Sinai initially ambulatory care at the hospital emergency room, negotiated with Aurora clinics to accept Medicare, and those needing ambulatory follow-up after Medicaid, and commercially insured patients; and receiving emergency care. In the years leading with the FQHCs to accept Title 19 and other up to the My Health Direct implementation in uninsured populations, as well as Medicaid and 2006, Aurora Sinai was losing almost $25 million Medicare patients. Shortly after the program began, a year, with a large portion of the loss attributed to it was decided to route most Medicare patients ambulatory care delivered in the emergency room, to Aurora clinics and most Medicaid patients to particularly to uninsured and Medicaid patients. FQHCs because of favorable reimbursement in the different settings. Receiving clinics control the At the time, Aurora Sinai’s emergency room averaged volume and type of patient routing by posting their 80,000 patient visits per year. In an effort to reduce schedules in My Health Direct. They also specify the losses and overcrowding, in 2005 the hospital type of services and insurance they will accept for implemented an emergency room triage program each appointment slot they post. designed to divert patients with routine care needs to ambulatory facilities. The program worked. Most emergency room clinicians, including However, it required turning patients away, a physicians, use the My Health Direct system to practice that led to criticism from the local press and arrange appointments for patients who do not declining morale among staff who found it difficult require emergency care. After accessing My Health to say “no” to patients who needed care and often Direct via a PC with an Internet connection, the did not understand how to arrange for it elsewhere. user first checks to see if the patient has a record in the system. If not, registering the patient requires In the words of Emergency Department Medical manually entering a small number of demographic Director Paul Coogan, M.D., providers and other data elements such as name, date of birth, telephone emergency room staff were begging for a way to, number, and home address. “get ‘em an appointment.” However the hospital did not have the staff resources to provide that The user then starts the referral process by specifying service quickly (a manual appointment process they the series of criteria to be used in matching the attempted to operate was slow and inefficient). patient with an appropriate service provider and appointment: patient insurance type, service type, Implementation distance from home, day of the week, preferred The appeal of using My Health Direct is that it language, and need for public transportation. has enabled staff to schedule an appointment while Based on the open appointment slots entered by the patient waits, and do so quickly (within two the participating receiving sites, My Health Direct to three minutes). As a result, instead of turning displays those that meet each characteristic as it is patients away, staff can provide them with confirmed specified; as more criteria are entered, the list of appointments and printed directions to the possible appointments is shortened to the matching ambulatory care site, and printed instructions. My subset. Sometimes, one or more criteria, such as Health Direct enables the hospital to supply similar distance from home, must be modified and another assistance to patients who receive emergency care search performed if the first round does not yield a and need help booking follow-up appointments. match acceptable to the patient. 20  |  C alifornia H ealth C are F oundation After consulting with the patient, the user selects and department visits have been reduced from almost confirms an appointment. This serves as a trigger for 80,000 to fewer than 43,000, staffing has been the system to automatically transmit a confirmation appropriately reduced, and patient wait times are notification to the receiving provider, including the shorter. Emergency room improvements also have reason for referral, and remove the appointment contributed to reducing overall hospital losses, from slot from availability for booking. The user then the previous levels of almost $25 million per year to prints a patient handout (in the patient’s language the “low single-digit(s).” of choice) that includes details about the referral such as appointment date and time, address of care In addition to shorter wait times, patients who come site, contact information, and public transportation to the emergency department needing ambulatory access. In addition to the reason for the referral and care get the unexpected (and welcome) service of basic patient information, the referral record also referral to a care site where they can be seen not includes a free-text field the referring provider can only for their immediate complaint but also find a use for clinical or other notes to the receiving facility. medical home for regular care. Though Aurora Sinai has not done extensive utilization analysis, staff there Referral records are retained in My Health Direct have determined that: for subsequent query and reporting. This provides K Ninety-two percent of patients referred via My access to not only the referral history and details Health Direct are not returning to the emergency for any patient, but also tallies of referral volumes department with ambulatory care needs; and by service types, patient insurance types, receiving provider sites, etc. When the provider initially opens K Four times as many My Health Direct a patient record, for example, before looking for appointments are kept after patients leave a new appointment, he or she can review all past the emergency department (compared with appointments made for that patient. appointments scheduled using the old, non-electronic methods). Results and Benefits Emergency department providers approved the Emergency room staff use My Health Direct to implementation and quickly adopted the system as schedule approximately 4,000 appointments per year part of their every day routine. The major benefit at Aurora Sinai. of the new program enabled by My Health Direct is that emergency room staff can triage patients, Challenges rather than turning them away with nothing more The major challenge Aurora Sinai has encountered than a list of recommended telephone numbers to with implementing and using My Health Direct is call. For emergency department staff, this has been a provider (and other user) dissatisfaction at having to huge morale booster. They report that the system is manually enter patient demographic data (address, quick and easy to use and are happy to have a way to telephone numbers, etc.) when registering new navigate between the financial realities of operating patients, rather than simply downloading it from the a hospital and the inevitable stream of ambulatory hospital system. My Health Direct has developed an patients with nowhere else to turn, leaving them interface that works with other systems. Aurora is in better able to focus on emergency care. the process of consolidating their patient databases and plans to provide an interface to My Health For hospital and emergency room administration, Direct by the end of 2008. the Web-based referral enabled effective use of the triaging program to improve emergency room utilization and operation. Annual emergency Bridging the Care Gap: Using Web Technology for Patient Referrals   |  21 La Clinica de Familia Web-based system as a way to make the process more standardized and manageable. Setting La Clinica de Familia (LCDF) operates nine Implementation community health centers providing medical, dental, inetMD is used in all of the medical clinics to and social services to a largely rural area of southern process referrals to a specialist or dental provider in New Mexico near the Mexican border. Clinic staff another LCDF clinic, or to an external specialist or include 20 physicians and five nurse practitioners. ancillary provider such as an imaging center. The Many of the patients served are indigent and must physician or nurse practitioner initiates the process travel quite a distance from small communities to by writing one or more referrals for the patient. receive care. Office clerks work with patients to arrange follow-up care. They first enter the request into inetMD, where Value Proposition they can check the patient’s past referral history to The majority of the medical services provided by see if the patient has already been referred for the LCDF are focused around primary care, so patients same service, and then select an appropriate site are typically referred to external providers for most after consulting with the patient about distances, specialty care, as well as diagnostic services such as transportation, and other compatibility criteria. imaging. Because the patient population has a high disease burden, especially diabetes, primary care visits Many patients’ care is covered by the county often generate one or more referrals. The goal at indigent care program or a special grant-funded LCDF is that patients needing a referral leave with a program, such as the one in place for mammograms scheduled appointment and without any unresolved and other breast care. All of the referral sites and reimbursement issues. To accomplish this, clerks in providers listed in inetMD accept these payers, as the medical clinics make all the necessary telephone well as Medicaid, Medicare, and commercial plans, calls while the patient is still in the clinic. so that the clerk knows that patients will not face insurance-related issues. Reimbursement counselors LCDF now uses inetMD as the information and are available in each LCDF site to sort out eligibility communication backbone of the referral program. and enroll the patient in plans and special programs Managing the process on paper created numerous as necessary. The office clerk enters the type of problems. Clerks were filling out forms for each insurance to be employed, and, when required by the referral and, because of the high volume, were often insurance carrier, calls to obtain authorization. The not able to keep up with such paperwork during clerk also calls the care site to obtain an appointment the clinic day. Once the patient had departed, it and enters the information about both the was extremely difficult to track individual referrals appointment date/time and insurance authorization and ensure they were completed successfully. number into the system. For some high-priority types of referrals, such as mammograms, relying on file folders or log sheets Patients leave with a printed copy of information was not only time-consuming but often ineffective. about scheduled referrals, including contact And because LCDF also had no information information in the event they cannot keep the on either the total volume of referrals or the appointment. The inetMD system automatically number of patients referred to individual receiving faxes to the receiving site. providers and sites, it could not accurately assess the overall performance of the referral program When the receiving provider transmits an (e.g., turnaround time, referrals without reports imaging report, a consult report, or other record received). Basically LCDF decided to invest in the communicating results back to the referring clinic, 22  |  C alifornia H ealth C are F oundation the medical records staff logs the receipt and the monthly rounds to provide training for new staff and result (i.e., normal or abnormal) into the system. refresher training as needed. LCDF ultimately plans Some types of referrals, such as mammograms and to expand the use of inetMD to include all referrals Pap smears, are tracked very closely—ensuring that emanate from the dental clinics, which now both that the testing happens and patients with participate only as “receiving sites.” abnormal findings receive timely and appropriate follow-up care. Medical record clerks can run Santa Clara Valley Health and reports in inetMD providing lists of outstanding Hospital System referrals (e.g., scheduled two weeks ago, but no report received) for outreach to the referral sites and Setting the patients involved (if, for example, the patient The Santa Clara Valley Health and Hospital needs to schedule another appointment). The System (SCVHHS) is an integrated health care clerks record any status updates in inetMD so that delivery system for residents of Santa Clara County, the referral can continue to be tracked. They can California. Facilities include Valley Medical Center, also set up an electronic reminder to check in on a with 435 beds and 500,000 annual outpatient and particular patient’s referral status at a future date. emergency room visits, approximately 150 specialists, Patients with an abnormal mammogram become the 10 primary care clinics, and several affiliated responsibility of a care coordinator who manages the community health centers. Many of the patients breast care program, using inetMD to arrange and served have Medi-Cal insurance or are uninsured. track follow-up care through further evaluation and treatment. Value Proposition Prior to implementing the program, patient referrals Results and Benefits within the health system were managed as paper The major benefit for LCDF is that the referral requests forwarded to a central authorization center process is now a manageable “closed loop.” Patients where they were manually reviewed, approved appreciate walking out with an appointment, and or denied, and scheduled. There were numerous LCDF has been able to institute an organized problems with this process: process for tracking referrals to completion. Staff K Requests frequently were lost in transit or within in medical records can easily obtain patient lists to the authorization center; use in outreach to patients and receiving providers without maintaining manual logs. For the first time, K Forms were often illegible and/or incomplete LCDF management can obtain complete tallies of (i.e., missing diagnosis, reason for visit); the volumes and types of referrals from the clinics K There was no way to track individual referrals, and identify where bottlenecks are occurring in and referring providers sometimes initiated completing all referrals in a timely fashion. The multiple requests for the same patient and process also works well for receiving providers —  problem; they have a legible referral request that includes the patient’s insurance information and any prior K Referring providers did not have adequate authorization. guidelines to make their decisions; K Referring providers often did not receive reports, Challenges progress notes, or other feedback from the According to the program director, one of the receiving provider; major challenges is constant staff turnover in the clinics. Front-office staff, nurses, and medical records technicians all use the system, and he makes Bridging the Care Gap: Using Web Technology for Patient Referrals   |  23 K Receiving providers did not always know who had automatically authorized at the point of referral, referred the patient and where to send consult and the patient either leaves the referring clinic reports or refer the patient for follow-up; with printed instructions for scheduling the visit, or (for pediatric referrals) with an appointment K Referrals were frequently misdirected; and that is scheduled before they leave. K SCVHHS often did not receive reimbursement K Requests for patients with other coverage are held for services provided to patients with insurance for payer approval and then forwarded. Referring coverage other than the county insurance providers also can request manual review of programs. special cases that do not meet clinical criteria. Valley Express was implemented to make it possible K Available online referral guidelines and clinical to improve referral management in all of these areas. practice guidelines can be directly accessed during referral request entry. Implementation K Staff in receiving provider sites review requests All SCVHHS referrals are now processed using the in their work queues in the system. Although Valley Express referral management system, which they do not further triage approved requests, they was purchased from Health Access Solutions and use the system to route questions or requests for implemented in July 2007. The system had been pre-visit work-ups back to the referring provider used previously in other settings and the vendor or forward special handling messages (such as made numerous modifications to accommodate the “first available slot”) to scheduling staff. SCVHHS environment. Valley Express also enables electronic communication The process involves the following steps: among the referring, receiving, and other providers. K Referring providers at the point of care initiate The system tracks the status and progress of requests, referral requests by entering patient identification sending automatic event messages (such as “referral information, the requested place of service, the approved”) to appropriate providers (including the specialty and/or a receiving provider, a diagnosis primary care clinician). Providers can use free-text code (ICD or CPT), and a reason for referral. note fields to describe patient conditions and ask or Coverage information is automatically populated answer questions. They also can attach scanned and via interface with the registration system. other electronic documents to referral records and print instructions for the patient. K Specialty-specific questions (up to three) are generated and yes/no responses are used to SCVHHS and clinic staff credit several tactics for automatically accept or deny the request. When the successful implementation of the Valley Express the request is denied, the reason is displayed. system: For example, if the referring provider answers “no” to “has patient failed at least two courses of K Discontinuing the practice of triage in the antibiotics?” the reply is, “at least two courses of specialty clinics has speeded the referral process antibiotics should be tried before ENT referral.” and clarified clinical appropriateness guidelines —  Questions and reasons for denial were developed although it took 12 months for the specialty by each specialty department to ensure clinical departments to reach consensus on a small appropriateness. number of guidelines (the maximum is three for each diagnosis/condition). The process was closely K For patients with coverage from Medi-Cal managed. Each department received a template, or another county program, requests that a list of the top ten diagnoses noted for referrals, pass clinical appropriateness rules are also 24  |  C alifornia H ealth C are F oundation and specific guidelines about how to state denial K Patient referral requests with no apparent responses. Questions were sent to referring insurance coverage (which further research providers for review and are continuously revealed indicate financial counseling had not reviewed as part of optimization efforts. occurred or failure to refer patients to their home counties); K A “big-bang” implementation strategy was used; i.e., all referring and receiving departments went K Emergency department referrals for chronic live at the same time, forcing an immediate conditions (such as low back pain, which should transition from the paper-based process. be directed to primary care clinics instead of treated in the emergency department); and K User training is mandatory. All clinic users (providers, nurses, medical assistants, and referral K Real numbers of submitted, approved, and denied coordinators) receive a 1.5-hour training course in referral requests (by receiving departments, how to use the system and maximize its potential. patient demographics, and payer/plan), as well as the extent of backlogs, durations, locations, and Results and Benefits seasonal shifts. SCVHHS staff have not been able to perform a formal study, however they have assembled Users suspect that recent reductions in no-show rates considerable anecdotal evidence of the system’s result from giving patients scheduling instructions success. The first positive reports came from referring or scheduling the referral visit at the point of care, primary care providers who immediately noticed as opposed to notifying the patient several days or that their requests were no longer being lost, and weeks later that an appointment has been scheduled. that auto-approval enabled them to confirm (or in the case of pediatric referrals confirm and schedule) Challenges referral approval with patients and give them SCVHHS offers the following lessons from their printed instructions to take with them. This also experience: has improved patient satisfaction because they now K Having physicians directly enter referral requests know that the referral has been approved and have is the most effective approach. Initially, some instructions about where to call for an appointment. physicians were reluctant to learn or take time out of their schedules to play this role. Training has Specialists were initially dissatisfied (primarily helped, but some clinics continue to use paper because they were accustomed to triaging requests forms and data entry by referral coordinators. manually) but have come to value the tools the system provides for tracking and managing approved K Grants contributed funding to add numerous referrals. workstations in clinics, but SCVHHS continues to work on ensuring sufficient high-speed access The other immediate benefit is reporting, which everywhere. already helps staff identify utilization and other situations that need attention. Examples include: SCVHHS uses an enterprise scheduling system that, ideally, would be interfaced with Valley Express. This K Outlier patient utilization trends, such as one would ensure that information about appointments patient who has been approved for 60 referral booked and kept is always complete for purposes of visits in less than 12 months; referral tracking. So far, creating such an interface K Ophthalmologist referrals to optometry (which has not proven to be possible. are not covered by insurance); Bridging the Care Gap: Using Web Technology for Patient Referrals   |  25 Cook County Health and Implementation Hospitals System IRIS is designed to manage several kinds of referrals, including: Setting K Primary care (and to a lesser extent hospital) The Cook County Health and Hospitals System providers referring patients for specialty care; and (CCHHS) in Illinois is one of the largest public health systems in the United States. It serves more K Emergency room, specialist, and hospital than 5 million citizens, operates three hospitals and providers referring patients to (or back to) 30 community health centers, coordinates specialty primary care clinics. care delivery throughout the network, and maintains partnerships and affiliations with other major Early on, it was decided that the system would medical centers and government agencies. CCHHS automatically approve or deny each referral also contracts to provide specialty care to patients of request based on clinical rules set by the receiving local independent FQHCs. department. Those rules are applied via a department- and disease-specific branching logic Value Proposition question-and-answer process included as part of In 2001, CCHHS contracted with Proximare the online referral request. Rules development was Health, Inc. to develop and implement the Internet a major undertaking and required department Referral Information System (IRIS) as part of an providers working with Proximare Health developers effort to improve management of patient referrals to specify questions, acceptable answers, branching within CCHHS provider organizations. Prior to options, and criteria for approval and denial, IRIS, referral requests were submitted as paper including reasons for denial. forms, and the system used to manage the forms resulted in numerous problems and shortcomings, The following describes the typical referral request, including: approval, scheduling, and visit workflow: K Lack of reliable and accurate utilization statistics K The referring provider completes an online CCHHS staff need to identify gaps in service and referral request form. Patient demographic data otherwise manage referral programs; are automatically downloaded via interface with the CCHHS patient registration system. K Misdirected and inappropriate referrals; After the provider enters the reason for referral, K Inadequate fail-safe measures to ensure that diagnostic service, and department name and patients with serious conditions were escalated site, the system automatically initiates the rules- for priority care; based question-and-answer process. Departments and sites are selected from pick lists that are K No central source or process for referring and screened by the referring provider and the place receiving providers to track referrals (to monitor of service. In addition to branching questions and approval and/or scheduling statuses); approval/denial status, receiving providers can K No standard method or process for referring also configure the rules with recommended and eligible patients (including Medicaid and required work-ups, which are displayed in a red uninsured) to primary care clinics; and font. Denials include explanations. For example, if a provider referring a patient for asthma responds K No processes to help reduce ambulatory patient that the patient is not using corticosteroid visits to emergency rooms. inhalers, the provider is instructed to initiate that treatment before referring the patient. 26  |  C alifornia H ealth C are F oundation K Referring providers who disagree with reasons for communication of results or consult report still to denial can appeal the decision, in which case the come. request is routed to a nurse care manager inbox for review. The system also flags request records Specialist and emergency department provider with entries the receiving provider determines to referrals (and referrals back) to primary care be high-priority and automatically routes those providers are also initiated by completion of an requests to the nurse care manager inbox for online referral request form. However, when primary special handling. care is selected as the receiving service, the system either: K The system manages appointment scheduling in one of two ways: K Displays a list of clinics that initiated a referral “Stand-in” scheduling. Receiving provider for the patient during the previous 24 months for departments that agree to participate in a selection and further processing; or “stand-in” appointment service post available K Displays clinics with appointment openings appointment dates and times in the IRIS system (posted by the clinic) and within a geographical by service and payer type. As soon as the slot range defined by the patient’s Zip code. is selected, it is closed to other IRIS users. The system automatically forwards a message to the Results and Benefits receiving provider, and instructions are printed Using IRIS has helped CCHHS improve referral and handed to the patient. management in many different ways: Central appointments. Referrals to receiving K Administrators now have real information departments that do not participate in the about demand/capacity gaps to use in allocating stand-in program are automatically routed to an resources. As a result, referral backlogs have been inbox in the Central Appointments department. reduced for mammography, colonoscopy, and When Central Appointments staff book and gynecology services. log the appointment date and time in IRIS, the system automatically sends messages to the K Referring providers have a reliable way to check referring provider, the receiving provider, and the status of each referral they request, including an intelligent voice response unit (IVR) used to whether patients are making and/or keeping notify the patient of the appointment date, time, appointments for referrals. and place. K Receiving providers appreciate the controls the K Receiving providers log each kept appointment IRIS process automatically imposes on incoming and referral visit. They also can paste a progress referrals. Applying rules-based guidelines has note into the record, which they are strongly almost completely eliminated the 20 to 25 encouraged to do. Messages of these logged events percent rate of misdirected referrals. According to also are sent to the referring provider. the medical director, it has enabled the CCHHS to “use specialists as specialists” — meaning that K Referring and receiving providers can review it has reduced the time specialists use making the status of any referral, including: those decisions about where patients should be seen pending a review or request for further and increased the time they spend delivering information; approved but not scheduled (and care. Inappropriate referrals (inadequate work-up the intervening elapsed time); approved and or failure to try standard therapies first) are also scheduled; appointments cancelled or not kept; substantially reduced. visits completed; and visits completed but with Bridging the Care Gap: Using Web Technology for Patient Referrals   |  27 K The system provides a framework that enables CCHHS to reliably manage more than 15,000 referrals per month. Using IRIS has made it possible to refer patients from the emergency department or hospital to primary care providers able to take new patients, and in the process helped clinics appropriately ramp up their utilization rates and helped emergency departments reduce patient demand and waiting time. Challenges The biggest challenge has been convincing providers to make consistent use of the system. Because the referral approval process is rules-based, it requires a clinical understanding of the questions being asked and what the responses mean, and therefore, is most effective when referring physicians do their own data entry. Similarly, since it includes a feedback loop for receiving providers to log kept visits, attach progress notes, and refer the patient back to the primary care provider for follow-up, it is most effective when both providers follow and track each referral and are sure to log events, including no-shows and cancellations. Another challenge is the level of effort required to develop and maintain clinical rules. Use of rules also requires careful version control, including version labeling, saved copies of each version, review and testing, and controlled release. 28  |  C alifornia H ealth C are F oundation Appendix A: Developer/Vendor Contact Information Homegrown Systems Commercial Products ER Connect Clinic Connect Access Express developed by : developed by : NetChemistry, Inc. Health Access Solutions Chris Cruttenden, president Dottie Robinson, executive director www.netchemistry.com www.healthaccesssolutions.com developed for : developed for : Orange County Health Care Agency Santa Clara Valley Health and Hospital System Dan Castillo, administrator Christine Tyler, director of special projects www.ochealthinfo.com www.sccgov.org/portal/site/hhs eReferral Eceptionist UCSF/San Francisco General Hospital Eceptionist, Inc. Hal Yee, Jr., M.D., Ph.D. Trey Havlick medicine.ucsf.edu/campuses/sfgh.html www.Eceptionist.com RPS (Referral Processing System) ERP/ERS Los Angeles Department of Heath Services inetMD, Inc. Hayley Buchbinder, staff analyst Khan Phi, president www.ladhs.org www.inetMD.net IRIS developed by : Proximare Health, Inc. Joe Sullivan, president www.proxhealth.com developed for : Cook Country Health and Hospitals System (CCHHS) Enrique Martinez, M.D., chief medical officer www.ccbhs.org My Health Direct Global Health Direct, Inc. Tom Reilly, VP Community Solutions www.globalhealthdirect.com Bridging the Care Gap: Using Web Technology for Patient Referrals   |  29 Appendix B: System Overview and Feature Review ER C o n n ec t My Health Direct eReferral RP S IRI S A cce ss E x p re ss C l i n i c C o n n ec t Ec epti o n i s t ERP/ ERS General Overview Product History Commercial Homegrown Homegrown Homegrown, now Commercial Homegrown Commercial Commercial Commercial Company or Global Health Direct, UCSF/San Francisco Los Angeles County Proximare Health, Health Access Orange County Eceptionist, Inc. inetMD, Inc. Developer Inc. General Hospital Department of Inc. Solutions Health Care Agency Health Services Typical Referral ED to PCP1 PCP to specialist/ PCP to specialist/ PCP to specialist/ PCP to specialist ED to PCP3 PCP to remote PCP to specialist/ Scenario(s) ancillary ancillary, specialist ancillary, and telemedicine ancillary to specialist ED/hospital to PCP2 receiving provider, and PCP to specialist/ancillary, any-to-any referral Typical Customer Hospital or Health Primary/Specialty Public Health Public Health Public Health Public Health Hospital or Health Community Health Today System Care Health System Network Network Network Network System Center or Network Pricing Model $50,000 per year, N/A N/A $50,000 per year, One-time: Custom pricing One-time: per hospital per IDN • $85,000, plus • $4,650/PCP clinic (system configuration/ • 2 cents per • $750/spec clinic, management extra) covered patient plus Subscription: • $75/mo/PCP • $45/mo/specialist Technology Overview Technology PC, Web access, PC, Web access, PC, Web access, PC, Web access, PC, Web access, PC, Web access, PC, Web access, PC, Web access, Required/ printer, fax VPN key printer, scanner printer, fax printer, scanner printer printer, scanner printer, scanner, fax Accommodated System Interfaces N/A ADT/registration, ADT/registration ADT/registration ADT/registration RHIO data repository Integrated N/A in Use receiving provider scheduling EMR 1. Clinics are screened by dates available, distance from patient home, patient language, and payer type/plan accepted. 2. Clinics screened for selection are those that have referred the patient within past 24 months, or (if no referrals) those with openings closest to patient home. 3. Clinics are pre-assigned via a separate OCHCA patient center assignment program. 30  |  C alifornia H ealth C are F oundation ER C o n n ec t My Health Direct eReferral RP S IRI S A cce ss E x p re ss C l i n i c C o n n ec t Ec epti o n i s t ERP/ ERS Functions/Features: Referral and Scheduling Referral Initiation Online PCP Online clinical Online clinical Online clinical Online clinical Online PCP referral Online clinical Online clinical scheduling with referral request with referral request with referral request with referral request with request with search referral request with referral request with search by: search by: search by: search by: search by: by: search by: search by: • Provider • Department • Department • Department • Department • Patient’s assigned • Department • Department • Language • Service • Service • Service • Service clinic4 • Service • Service • Provider gender • Diagnosis, plus • Diagnosis • Location Online PCP • Payer type/plan scheduling with • Date/time search by: • Religion • Care history • Service type • Location • Public transportation Administrative N/A N/A Referral request Optional online Optional online N/A Optional online Optional online Approval records routed to payer authorization payer authorization payer authorization payer authorization authorization work queue Scheduling Referring provider Receiving provider Receiving provider Referring provider Patient calls Notified receiving Notified receiving Referring provider selects from schedules books appointment selects from receiving provider to PCP office calls provider contacts attempts to book appointments appointment based appointments book appointment patient to book patient to book before patient posted by receiving on urgency posted by receiving appointment appointment leaves, or patient provider5 provider, or (Eceptionist supports is instructed to call approved referrals multiple scheduling receiving provider are routed to Central models) to book appointments Schedule Access Receiving provider Receiving provider N/A “Stand-in” receiving N/A N/A N/A N/A Control posts: can prioritize providers post: • Dates/times appointments • Dates/times • Payers • Payers • Services • Services Patient Notification Referring provider Patient receives a • Receiving provider • Referring provider Referring provider Referring provider • Referring provider Referring provider prints patient computer generated mails or faxes prints patient mails or faxes prints handout with mails, emails, mails or faxes handout appointment letter handout, and approval with receiving clinic faxes, or hands letter with contact notification letter • Referring provider • IVR6 scheduling contact information letter with contact or appointment and subsequent tracks and informs instructions information information reminder letter • A patient portal and email/text message based patient notification and reminder tools also are available 4. Clinics are pre-assigned via a separate OCHCA patient center assignment program 5. Selection of limited scheduling slots manually entered by receiving provider — system is not interfaced to a full-featured scheduling system. 6. Intelligent Voice Response unit: an automated telephone system that notifies patients of new appointments (in selected languages). Bridging the Care Gap: Using Web Technology for Patient Referrals   |  31 ER C o n n ec t My Health Direct eReferral RP S IRI S A cce ss E x p re ss C l i n i c C o n n ec t Ec epti o n i s t ERP/ ERS Functions/Features: Referral and Scheduling, continued Receiving Provider Receiving provider Receiving provider Completed referral Completed referral Approved referral Completed referral Completed referral Completed referral Notification receives message7 receives computer- request posted to records (with status posted to record posted to request posted to request is posted to or fax generated email receiving provider appointment receiving provider receiving provider receiving provider receiving provider inbox updates) posted to inbox and provider inbox inbox inbox or faxed receiving provider receives message inbox and provider receives message Referral Status Providers review all Providers track Providers review Providers review Providers review Providers review Providers review Providers review Tracking scheduled referrals status via EMR referral inbox referral inbox referral inbox customized work referral inbox referral inbox for approval and for approval and for approval and queue for referrals for approval and for approval and appointment status appointment status appointment status to PCP clinic appointment status appointment status changes changes. Also changes changes changes. Also can track pending can track pending progress notes progress notes Referring Provider N/A Automatic message Approval and Automatic message Automatic message N/A Automatic message Automatic message Notification when approval or appointment are when schedule when schedule when approval or when approval or schedule status is posted in referral status is updated status is updated schedule status is schedule status is updated record updated updated Functions/Features: Clinical Review and Approval Clinical Information Referring provider Referring provider: Referring provider: Referring provider: Referring provider: Access to patient’s Referring provider: Referring provider: Sent with Referral documents with • Documents with • Documents with • Documents via • Documents via hospital visit and • Documents via • Documents with free text free text free text responses to responses to rules claims-based lab, template free text branching rules queries other diagnostic, and • Responds to • Attaches scanned • Documents with • Attaches scanned queries medication history department and other files • Documents with free text and other files specific queries free text • Attaches scanned • Specialty-pertinent • Attaches scanned and other files lab and radiology and other files data automatically populates referral record Clinical Review N/A Receiving provider Receiving provider Automatic approval Automatic approval N/A Receiving provider Receiving provider reviews referral reviews referral based on rules8 based on rules9 reviews referral reviews referral record record record record Referral Guidelines N/A N/A Receiving provider Receiving provider Direct access N/A Client can configure Receiving provider can configure can configure (button) to online custom referral can configure pop-up requisites in rules with red-text IDN guidelines protocols request entry request entry prerequisites prerequisites 7. Messages are postings to referral record and/or system messages, usually accompanied by an email or fax alerting provider that new information is available. 8. Referring providers can appeal denied referrals for manual review by a nurse care manager team 9. Referring providers can appeal denied referrals for manual review by the Chief of Referral Services 32  |  C alifornia H ealth C are F oundation ER C o n n ec t My Health Direct eReferral RP S IRI S A cce ss E x p re ss C l i n i c C o n n ec t Ec epti o n i s t ERP/ ERS Functions/Features: Other Information Exchange Feedback Loop to N/A • Information • Information • Information • Information PCP progress • Information • Information Referring Provider requests requests requests requests notes posted to the requests requests • Work-up requests • Work-up requests • Work-up requests • Work-up requests record are available • Work-up requests • Work-up requests for review during • Denial reason(s) • Denial reason(s) • Recommend • Appointment kept, • Denial reasons • Denial reasons subsequent ED • Appointment kept, • Appointment kept, redirect, e.g. for cancel, no-show • Appointment kept, • Appointment kept, visits cancel, no-show cancel, no-show different test • Attach progress cancel, no-show cancel, no-show • Link to EMR • Scanned progress • Appointment kept, note • Attached progress • Attached progress progress note notes cancel, no-show notes notes • Attached progress notes Link to Patient N/A Receiving provider Receiving provider Receiving provider Receiving provider RHIO ED progress Receiving provider Receiving provider Records posts link to EMR can attach progress can attach progress can attach progress note is available for can attach progress can attach progress progress note notes, reports notes, reports notes, reports review by PCP notes, reports notes, reports Functions/Features: Data Tracking and Analysis Management Library of standard Library of standard Library of standard Library of standard Library of standard Library of standard Library of standard Library of standard Reports reports reports and report reports reports and report reports reports and report reports and report reports and report writer writer writer writer writer Functions/Features: Planned Enhancements Planned • IDN MPI interface N/A • Scheduling system • Duplicate order • Scheduling system N/A N/A N/A Enhancements pilot interface checking interface • Automated • EMR interface – • Branding • Report writer appointment progress note (custom rules for • Branching logic reminders different payers/plans) • Report writer rules • Receiving clinic • Ambulatory EMR scheduling system interface interface Bridging the Care Gap: Using Web Technology for Patient Referrals   |  33 C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org