Electronic referral systems in health care: a scoping review

Improving Access to Specialty Pediatric Care: Innovative Referral and eConsult Technology in a Specialized Acute Care Hospital

Background: The COVID-19 pandemic has exacerbated wait times for pediatric specialty care. Transformative technologies such as electronic referral (eReferral-automation of patient information) and electronic consultations (eConsult-asynchronous request for specialized advice by primary care providers) have the potential to increase timely access to specialist care. The objective of this study was to present an overview of the current state and characteristics of referrals directed to a pediatric ambulatory medical surgery center, with an emphasis on the innovative use of an eConsult system and to indicate key considerations for system improvement. Methods: This cross-sectional study was conducted at a specialized pediatric acute care hospital in Ottawa, Ontario. Secondary data were obtained over a 2-year period during the COVID-19 pandemic (2019-2022). To gain insights and identify areas of improvement related to the factors pertaining to referrals and eConsults at the process and system levels, quality improvement (QI) methodologies were employed. Descriptive statistics provide a summary of the trends and characteristics of referrals and the utilization of eConsult. Results: Among the 113,790 referrals received, 31,430 were denied. Most common reasons for referral denial were other/null (e.g., unspecified) (29.3%), inappropriate referrals (12.6%), and duplicate referrals (12.4%). Four clinics (e.g., endocrinology, cardiology, neurology, and neurosurgery) reported a total of 277 eConsults, with endocrinology accounting for 95.0% of all eConsults. QI findings revealed the need for standardized workflows among specialties and ensuring that eConsult options are accessible and integrated within the electronic medical record (EMR). Conclusions: Refining the pediatric referral management process and optimizing eConsult through existing clinical systems have the potential to improve the timeliness and quality of specialty care. The results inform future research initiatives targeting improved access to pediatric specialty care and serve as a benchmark for hospitals utilizing EMRs and eConsult.

External Vs Internal e-Referrals: Results from a Nationwide Epidemiological Study Utilizing Secondary Collected Data

Background

E-referral systems, streamlining patient access to specialists, have gained global recognition yet lacked a comparative study between internal and external referrals in Saudi Arabia (KSA).

Methods

This retrospective study utilized secondary data from the Saudi Medical Appointments and Referrals Centre system. The data covers 2020 and 2021, including socio-demographic data, referral characteristics, and specialties. Logistic regression analysis was used to assess factors associated with external referrals.

Results

Out of 645,425 e-referrals from more than 300 hospitals, 19.87% were external. The northern region led with 48.65%. Males were 55%, and those aged 25-64 were 56.68% of referrals. Outpatient clinic referrals comprised 47%, while 61% of referrals were due to a lack of specialty services. Several significant determinants are associated with higher rates of external referral with (p-value <0.001) and a 95% Confidence interval. Younger individuals under 25 exhibit higher referral rates than those aged 25-64. Geographically, compared to the central region, in descending order, there were increasing trends of external referral in the northern, western, and southern regions, respectively (OR = 19.26, OR = 4.48, OR 3.63). External referrals for outpatient departments (OPD) and dialysis services were higher than for routine admissions (OR = 1.38, OR = 1.26). The rate of external referrals due to the lack of available equipment was more predominant than other causes. Furthermore, in descending order, external referrals for organ transplantation and oncology are more frequent than for medical specialties, respectively (OR = 9.39, OR = 4.50).

Conclusion

The study reveals trends in e-referrals within the KSA, noting regional differences, demographic factors, and types of specialties regarding external referrals, benefiting the New Model of Care for the 2030 Vision. Findings suggest expanding virtual consultations to reduce external referrals. Strengthening primary care and preventive medicine could also decrease future referrals. Future studies should assess resource distribution, including infrastructure and workforce, to further inform healthcare strategy.

Assessing Medical Emergency E-referral Request Acceptance Patterns and Trends: A Comprehensive Analysis of Secondary Data From the Kingdom of Saudi Arabia

Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.

Digitalization in orthopaedics: a narrative review

Advances in technology and digital tools like the Internet of Things (IoT), artificial intelligence (AI), and sensors are shaping the field of orthopaedic surgery on all levels, from patient care to research and facilitation of logistic processes. Especially the COVID-19 pandemic, with the associated contact restrictions was an accelerator for the development and introduction of telemedical applications and digital alternatives to classical in-person patient care. Digital applications already used in orthopaedic surgery include telemedical support, online video consultations, monitoring of patients using wearables, smart devices, surgical navigation, robotic-assisted surgery, and applications of artificial intelligence in forms of medical image processing, three-dimensional (3D)-modelling, and simulations. In addition to that immersive technologies like virtual, augmented, and mixed reality are increasingly used in training but also rehabilitative and surgical settings. Digital advances can therefore increase the accessibility, efficiency and capabilities of orthopaedic services and facilitate more data-driven, personalized patient care, strengthening the self-responsibility of patients and supporting interdisciplinary healthcare providers to offer for the optimal care for their patients.

Evaluating the design of the Integrated Care for Older People: a theory of change approach

Introduction

Given the progressive aging of the population, there is an urgent need at the health system level to implement effective models to care for older people (OP). Healthy aging is imperative to reach the Sustainable Development Goals. The World Health Organization (WHO) developed the Integrated Care for Older People (ICOPE) strategy to address this challenge. Implementing ICOPE requires its adaption to a specific context. We propose a pathway for such adaptation through an evaluation of the design of ICOPE; thus, we aim to describe the Theory of Change (ToC) of ICOPE and evaluate it for its implementation in Mexico City.

Methods

Based on the WHO and published literature documentation, we drafted an initial ToC for ICOPE. Then, we validated the ToC with experts in ICOPE, after which we evaluated and refined it by discussing the causal pathway, intervention required to activate it, rationale, and assumptions in consecutive workshops with 91 stakeholders and healthcare workers, using the nominal group technique to reach a consensus.

Results

The resulting ToC has the potential to contribute to healthy aging by three expected impacts: (1) prevention, reversal, or delaying of the decline of intrinsic capacity (IC) in OP; (2) improvement of the quality of life of OP; and (3) increase of disability-free life expectancy. The ICOPE causal pathway had ten preconditions, including the availability of resources, identifying at-risk individuals, available treatments, and evaluating results.

Discussion

We adapted ICOPE to a specific implementation context by evaluating its ToC in a participatory process that allows us to identify challenges and address them, at least in terms of the guidelines to operate the strategy. As ICOPE is an approach for a primary healthcare system, its adoption in a community healthcare program is promising and feasible. Evaluation as a tool could contribute to the design of effective interventions. The evaluation of the design of ICOPE for its implementation contributes to the strength of its potential to improve care for OP. This design for implementing ICOPE has the potential to be applied to similar contexts, for example, in other lower-middle-income countries.

Lessons Learned from Natural Disasters around Digital Health Technologies and Delivering Quality Healthcare

As climate change drives increased intensity, duration and severity of weather-related events that can lead to natural disasters and mass casualties, innovative approaches are needed to develop climate-resilient healthcare systems that can deliver safe, quality healthcare under non-optimal conditions, especially in remote or underserved areas. Digital health technologies are touted as a potential contributor to healthcare climate change adaptation and mitigation, through improved access to healthcare, reduced inefficiencies, reduced costs, and increased portability of patient information. Under normal operating conditions, these systems are employed to deliver personalised healthcare and better patient and consumer involvement in their health and well-being. During the COVID-19 pandemic, digital health technologies were rapidly implemented on a mass scale in many settings to deliver healthcare in compliance with public health interventions, including lockdowns. However, the resilience and effectiveness of digital health technologies in the face of the increasing frequency and severity of natural disasters remain to be determined. In this review, using the mixed-methods review methodology, we seek to map what is known about digital health resilience in the context of natural disasters using case studies to demonstrate what works and what does not and to propose future directions to build climate-resilient digital health interventions.

Designing and describing an electronic referral system to facilitate direct hospital admissions

Background

In France, the progressive use of emergency departments (EDs) by primary care providers (PCPs) as a point of access to hospitalization for nonurgent patients is one of the many causes of their overcrowding. To increase the proportion of direct hospital admissions, it is necessary to improve coordination between PCPs and hospital specialists. The objective of our work was to describe the design and implementation of an electronic referral system aimed at facilitating direct hospital admissions.

Methods

This initiative was conducted in a French area (Hauts-de-Seine Sud) through a partnership between the Antoine-Béclère University Hospital, the Paris-Saclay University Department of General Medicine and the local health care network. The implementation was carried out in 3 stages, namely, conducting a survey of PCPs in the territory about their communication methods with the hospital, designing and implementing a web-based application called “SIPILINK” (Système d'Information de la Plateforme d’Intermédiation Link) and an innovative organization for hospital management of the requests, and analysing through descriptive statistics the platform use 9 months after launch.

Results

The e-referral platform was launched in November 2019. First, a PCP filled out an electronic form describing the reason for his or her request. Then, a hospital specialist worked to respond within 72 h. Nine months after the launch, 132 PCPs had registered for the SIPILINK platform, which represented 36.6% of PCPs in this area. Of the 124 requests made, 46.8% corresponded to a hospitalization request (conventional or day hospitalization). The most requested specialty was internal medicine (48.4% of requests). The median time to first response was 43 min, and 43.5% of these requests resulted in direct admission (conventional or day hospitalization).

Conclusions

This type of system responds to a need for coordination in the primary-secondary care direction, which is less often addressed than in the secondary-primary care direction. The first results show the potential of the system to facilitate direct admissions within a short time frame. To make the system sustainable, the next step is to extend its use to other hospitals in the territory.

Scaling up a National Extracorporeal Membrane Oxygenation Referral Service for adult patients in acute severe respiratory failure at the time of a pandemic

The National ECMO Service for patients in acute severe respiratory failure in England responded to the challenge of the coronavirus pandemic by implementing a central electronic referral system within days. Prior to this, each ECMO centre managed independently around 20 ECMO referrals per month. Early during the pandemic, we recognised the need for a referral system to co-ordinate the anticipated increased number of referrals. We implemented rapidly a referral system with universal access across England. This allowed the five National ECMO centres to manage over 1000 referrals in the first seven weeks of the pandemic. Key benefits of the new system included facilitated communication and collaboration between centres; data on demand; and capacity shared in real-time. We believe this was instrumental in allowing us to continue to provide for the whole country, respond at scale, and facilitate our collaborative work as a multidisciplinary team.

Perception and Attitude toward Teleconsultations among Different Healthcare Professionals in the Era of the COVID-19 Pandemic

Teleconsultation has become one of the most important and sometimes the only possible forms of communication between healthcare professionals (HCPs) and their patients during the COVID-19 pandemic. The perceptions and attitudes of HCPs to teleconsultations may affect the quality of the therapeutic process provided using them. Therefore, this study aimed to understand the attitudes to and perceptions of medical teleconsultation among various HCPs during the COVID-19 pandemic. We analyzed data from a dedicated questionnaire on preferences, attitudes, and opinions about teleconsultation, which was filled by 780 Polish HCPs. Most of the HCPs were doctors and nurses (69% and 19%, respectively); most of the doctors were family physicians (50.1%). During the pandemic, teleconsultation and face-to-face contact were reported as the preferred methods of providing medical services with similar frequency. Doctors and nurses displayed the most positive attitude toward teleconsultation while the paramedics and physiotherapists took the least positive view of it. The most frequently indicated ratio of the optimal number of teleconsultations to in-person visits in primary health facilities care was 20%:80%. Most HCPs appreciate the value of teleconsultation, and more than half of them are willing to continue this form of communication with the patient when necessary or desirable.

Reasonable requests: echocardiography referral forms as a measure of coherent clinical communication

BACKGROUND

Well performed clinical communication is a cornerstone of collaborative care in medicine but may be confounded by inconsistent intentions of the messenger and biased interpretation by the recipient. A comparison of the findings of electronic echocardiography reports with clinician-completed standardised request forms provided an opportunity to assess communication quality.

AIM

The study aimed to determine clinician aptitude to complete written echocardiography referral forms by assessing the completeness, appropriateness, accuracy, and coherency of the reported clinical findings, conclusions and requests made on the referral forms. The study explored factors that may influence the quality of communication through this referral medium.

METHODS

A retrospective cohort study was conducted on patients who underwent trans-thoracic echocardiography imaging at Cecilia Makiwane Hospital in East London over 26 months. Paper echocardiography request forms that recorded the requesting clinician's findings on examination, the provisional clinical diagnosis, and the specific echocardiographic information sought, were compared with the actual findings on echocardiography.

RESULTS

Of 613 request forms reviewed, 97 cases were excluded due to illegibility or because they lacked analysable information or requester details, leaving 516 forms suitable for study. No pathology was found on echocardiography in 31%. Of the murmurs expected from the echocardiography findings, only half were recorded on the request form (sensitivity and positive predictive value both 52%.). Only 35% of request forms that mentioned a mitral systolic murmur gave a working diagnosis of mitral regurgitation and only 38% of request forms that mentioned an aortic systolic murmur considered aortic stenosis. Clinically suspected cardiomyopathy (CMO) had a PPV of 43% and echocardiographic CMO was missed clinically in 41%. Apex beat displacement reported clinically was not associated with echocardiographic LV dilatation in 65% of cases. One-third (34%) of forms reporting murmurs did not request valve function assessment and 17% considering cardiomyopathy did not request left ventricular function assessment.

CONCLUSION

Echocardiography request forms highlight vulnerabilities in clinical communication. Specifically, important clinical features were missing and more concerningly, included when unlikely to be present. There was a lack of concordance between recorded clinical findings and postulated diagnoses. Clinicians sometimes appeared unclear about the value or appropriateness of the requested assistance. Greater emphasis on teaching examination and communication skills may foster safer and more efficient use of scarce resources.

Systems engineering analysis of diagnostic referral closed-loop processes

BACKGROUND

Closing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%-73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes.

OBJECTIVE

Conduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case.

METHODS

An interdisciplinary team of clinicians, systems engineers, quality improvement specialists, and patient representatives collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health centre and a teaching practice within a large academic medical centre. Results were used to conduct an engineering process analysis, assess variation within and between practices, and identify common failure modes and potential solutions.

RESULTS

Processes to complete diagnostic referrals involve many sub-standard design constructs, with significant workflow variation between and within practices, statistical instability and special cause variation in completion rates and timeliness, and only 21% of all process activities estimated as value-add. Failure modes were similar between the two practices, with most process activities relying on low-reliability concepts (eg, reminders, workarounds, education and verification/inspection). Several opportunities were identified to incorporate higher reliability process constructs (eg, simplification, consolidation, standardisation, forcing functions, automation and opt-outs).

CONCLUSION

From a systems science perspective, diagnostic referral processes perform poorly in part because their fundamental designs are fraught with low-reliability characteristics and mental models, including formalised workaround and rework activities, suggesting a need for different approaches versus incremental improvement of existing processes. SE perspectives and methods offer new ways of thinking about patient safety problems, failures and potential solutions.

Under viral attack: An orthopaedic response to challenges faced by regional referral centres during a national cyber-attack

BACKGROUND

A national ransomware attack on the Irish Health Service Executive left the Healthcare system bereft of access to IT systems, electronic patient records, and the national imaging system. Widespread disruption to internal and external referral pathways, and both trauma and elective Orthopaedic services occurred as a result. The purpose of this paper to discuss the challenges faced by Regional trauma units and adjustments made to overcome these.

METHODS

Issues occurring as a result of the IT cybersecurity attack were discussed at regional level. Local and specialist centre adaptations were collated to identify effective modifications to established practice in the wake of the IT attack.

RESULTS

The main areas affecting Orthopaedic regional practice were identified, including internal referrals, interhospital referrals to both regional and specialist centres, outpatient clinics, and elective practice. Strategies to overcome these were collated and shared between regional centres, including the use of secure messaging systems to safely transmit relevant clinical information between services, use of radiological hard copies, and integration of imaging resources to the outpatient department to expedite clinical review.

CONCLUSION

The national cyberattack necessitated rapid adaptations to overcome the challenges faced as a result of reduced clinical and radiological access. While the recent cyberattack highlights the vulnerability of electronic systems, and the need for vigilance including staff training on cybersecurity; Changes implemented by regional centres also illustrate the potential for further development and expansion of current clinical practices.

Factors affecting the successful implementation of the referral system: A scoping review

An effective referral system ensures that there is a close relationship among all levels of health care, and individuals can receive the best possible care. The main purpose of the present study was to summarize studies that have addressed factors affecting the successful implementation of the referral system. A scoping review was performed to identify English and Farsi papers that were indexed in PubMed, Scopus, Science Direct, Trip Database, Cochrane Library, Embase, Google Scholar, SID, and Magiran until November 2020. Data was collected from the included studies by a reviewer and was checked by a second reviewer the collected data was analyzed using narrative methods. About 1245 relevant studies were identified in the first stage. After checking titles and abstracts, 63 studies were included. The factors that affected the referral system were classified in 4 themes and fourteen subthemes including technology (electronic referral, coordination, response and feedback), processes (effectiveness, efficiency), organizational (management, policy and planning, rules and regulations), patient centered individual (insurance coverage, social capital, transportation, awareness, attitude, satisfaction, and social influence). Therefore, a wide range of factors are affecting the performance of referral systems. For implementing an effective referral system, it is necessary to consider these factors.

Effectiveness of telephone-based screening and triage during COVID-19 outbreak in the promoted primary healthcare system: a case study in Ardabil province, Iran

Aims

Screening services for early detection of patients is one of the important capabilities of the health system with a proper referral system. In the crisis of respiratory infection of Covid-19, screening based on symptoms is one of the key measures. The aim of the current study was to evaluate the telephone-based screening and triage services in the promoted primary healthcare system with regard to the Covid-19 outbreak, in terms of reducing unnecessary referrals to the hospital.

Methods

This is a descriptive cross-sectional study conducted in two stages on 1,406,635 households during March/April 2020 in Ardabil province for screening and early detection of Covid-19 disease. In the first stage, conducted by trained healthcare providers through telephone, individuals suspected of Covid-19 were identified. In the second stage, the individuals were referred to the second level of service in comprehensive healthcare centers (16- or 24-h centers) for clinical evaluation by a physician.

Results

The results showed that before establishing a screening and triage system for patients in comprehensive healthcare centers, all patients were referred directly to the hospital, while after the implementation of the program, a significant reduction in hospital visits was observed and a large number of patients undertook the care and triage services in comprehensive healthcare centers.

Conclusion

The use of a grading system in referring patients with suspected cases, triage of patients according to symptoms at the comprehensive health centers, and activation of home isolation were the most important factors in reducing the burden of unnecessary referrals of patients to the hospital.

Design and development of referrals automation, a SMART on FHIR solution to improve patient access to specialty care

Background

Referring patients to specialty care is an inefficient and error-prone process. Gaps in the referral process lead to delays in patients' access to care, negative patient experience, worse health outcomes, and increased operational costs. While implementation of standards-based electronic referral options can alleviate some of these inefficiencies, many referrals to tertiary and quaternary care centers continue to be sent via fax.

Objective

We describe the design process and architecture for a software application that has been developed and deployed to optimize the referrals intake process by automating the processing and digitization of incoming specialty referral faxes, extracting key data elements and integrating them into the electronic health record (EHR), and organizing referrals.

Methods

A human-centered design approach was used to identify and describe the inefficiencies in the external referral process at our large, urban tertiary care center. Referrals Automation, an application to convert referral faxes to digital referrals in the EHR, was conceptualized based on key stakeholder interviews and time and motion studies. This application was designed using Substitutable Medical Applications and Reusable Technologies (SMART) and Fast Healthcare Interoperability Resource (FHIR) platforms to allow for adaptability into other healthcare organizations.

Results

Referrals Automation software was developed as a healthcare information technology solution to streamline the fax to referral process. The application was implemented into several specialty clinics. Metrics were built-in to the applications to evaluate and guide the further iteration of these features.

Conclusions

Referrals Automation will enhance the referrals process by further streamlining and organizing the patient referral process.

What patients with lung cancer with comorbidity tell us about interprofessional collaborative care across healthcare sectors: qualitative interview study

BACKGROUND

Patients with lung cancer with comorbidity often require treatment and care by different health professionals, in different settings and at different points in time during the course of the disease. In order to organise and coordinate healthcare efficiently, effective information exchange and collaboration between all involved care providers are required. The aim of this study was to assess the views of patients with advanced lung cancer with comorbidity regarding coordination of treatment and care across healthcare sectors.

METHODS

This qualitative study, as part of the main study, The Heidelberg Milestones Communication Approach, used face-to-face guide-based semistructured interviews with patients with advanced lung cancer and their informal caregivers to explore cross-sectoral information exchange and collaboration in Germany. All generated data were audio-recorded, pseudonymised and transcribed verbatim. Data analysis was performed using qualitative content analysis to structure data into themes and subthemes. All data were managed and organised in MAXQDA.

RESULTS

In 15 interviews, participants reported that cross-sectoral collaboration functioned well, if treatments occurred as planned. However, treatment gaps were experienced, especially regarding medication and regimen. As a result, participants felt insecure and obliged to take responsibility for the coordination of healthcare. Patients reported to be in favour of an active patient role but felt that healthcare coordination should still be a responsibility of a care provider. A more intensive information exchange, potentially by using an electronic platform, was expected to strengthen cross-sectoral collaboration.

CONCLUSION

Patients with lung cancer are uncertain about their role in the coordination of treatment and care across healthcare sectors. Healthcare providers should be more aware of care recipients' willingness of taking on a more active role in healthcare coordination.

TRIAL REGISTRATION NUMBER

DRKS00013469.

Specialist Participation in e-Consult and e-Referral Services: Best Practices

Electronic consultations (eConsults) and referrals (eReferrals) are being implemented to improve access to specialist care. As eConsult and eReferral services rely on a roster of engaged specialists for their success, careful attention must be paid to how the term "specialist" is defined, what criteria inform specialists recruitment, and how quality of specialist responses can be monitored and maintained. Key considerations, informed by our personal experiences, review of best practice documents, international frameworks of specialists roles and competencies and a focused small group discussion among providers, health service planners and researchers for each of these important elements is discussed. Individuals participating in services should receive clear expectations around their role and responsibilities and be provided equitable access assuming they meet the necessary requirements. Training and feedback should be provided to ensure timely, quality responses. Paying attention to these key elements will reduce confusion, frustration and disengagement amongst specialists and ensure high quality responses.