Introduction of electronic referral from community associated with more timely review by secondary services

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.

Dental referrals for patients with diabetes: survey of barriers and enablers for medical and health professionals

BACKGROUND

Oral health care improves diabetes management; however, medical and other health practitioners do not commonly refer their patients with diabetes for oral health care. This study aimed to understand barriers to and enablers of dental referrals for patients with diabetes.

METHODS

Quantitative data were collected from a cross-sectional survey of health care providers attending a virtual Grand Rounds on the relationship between oral health and diabetes. Attendees were invited to complete and share a Forms survey. Barriers to and enablers of dental referrals were compared for 18 health professionals working in inpatient/ward settings to 23 working in community/primary care settings using the chi-square test.

RESULTS

Across both work settings, only 12% of respondents often or always discussed the importance of oral health and only 8% often or always referred their patients with diabetes for dental care. Time barriers, awareness and knowledge of how/where to send dental referrals were significant barriers, while online referral pathways, more education and availability of brochures for the patient to take home were identified as key enablers for dental referrals.

CONCLUSIONS

Online referral pathways, targeted oral health education and resources for medical and health professionals caring for patients with diabetes may increase the number of patients being referred for dental care as part of their diabetes managements. © 2023 Australian Dental Association.

A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies

BACKGROUND

The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process.

METHODS

A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis.

RESULTS

A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified.

CONCLUSIONS

Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.

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.

Improvement of the Efficiency and Completeness of Neuro-Oncology Patient Referrals to a Tertiary Center Through the Implementation of an Electronic Referral System: Retrospective Cohort Study

Background

Quality referrals to specialist care are key for prompt, optimal decisions about the management of patients with brain tumors.

Objective

This study aimed to determine the impact of introducing a Web-based, electronic referral (eReferral) system to a specialized neuro-oncology center, using a service-developed proforma, in terms of waiting times and information completeness.

Methods

We carried out a retrospective cohort study based on the review of medical records of referred adult patients, excluding follow-ups. Primary outcome measures were durations of three key phases within the referral pathway and completion rates of six referral fields.

Results

A total of 248 patients were referred to the specialist center during the study period. Median (IQR) diagnostic imaging to referral intervals were 3 (1-5) days with eReferrals, and 9 (4-19), 19 (14-49), and 8 (4-23) days with paper proforma, paper letter, and internal referrals, respectively (P<.001). Median (IQR) referral to multidisciplinary team decision intervals were 3 (2-7), 2 (1-3), 8 (2-24), and 3 (2-6) days respectively (P=.01). For patients having surgery, median (IQR) diagnostic imaging to surgery intervals were 28 (21-41), 34 (27-51), 104 (69-143), and 32 (15-89) days, respectively (P<.001). Proportions of complete fields differed significantly by referral type in all study fields (all with Ps <.001) except for details of presentation, which were present in all referrals. All study fields were always present in eReferrals, as these are compulsory for referral submission. Depending on the data field, level of completeness in the remaining referral types ranged within 69% (65/94) to 87% (82/94), 15% (3/20) to 65% (13/20), and 22% (8/41) to 63% (26/41) in paper proforma, paper letter, and internal referrals, respectively.

Conclusions

An electronic, Web-based, service-developed specific proforma for neuro-oncology referrals performs significantly better, with shorter waiting times and greater completeness of information than other referral types. A wider application of eReferrals is an important first step to streamlining specialist care pathways and providing excellent care.

International Registered Report Identifier (IRRID)

RR2-10.2196/10.2196/15002

Electronic Advice Request System for Nephrology in Alberta: Pilot Results and Implementation

Background:

Residents of rural areas of Alberta face significant barriers regarding access to specialist care, resulting in delays in provision of optimal care. Electronic referral and consultation systems are promising tools for facilitating timely access to specialist care, especially for people living in rural locations.

Objective:

To report our initial experience with the launch of an electronic advice request system for ambulatory kidney care in Alberta, Canada.

Methods:

We analyzed electronic advice requests for nephrology services in Alberta after the system’s pilot launch, from October 2016 to December 2017. Data for province-wide advice request utility by primary care providers (PCPs) were extracted from Alberta Netcare for analysis.

Results:

The total number of electronic advice requests directed to nephrology was 118 (mean number of requests: 2 per week). Only 31 (26.3%) of the cases required a face-to-face clinic visit with a nephrologist. Most (87; 73.7%) cases were managed by PCPs with ongoing nephrologist support via the advice request tool. Typical nephrologist response time was 5.7 ± 0.6 (mean ± SEM) days.

Conclusion:

These preliminary data suggest that the electronic advice request program has potential to enhance timely access to specialist kidney care and minimize unnecessary nephrologist visits while reducing response time. Broad implementation of this system may have a substantial positive impact on health outcomes and improve cost-effectiveness for nephrology care in the long term, particularly in rural communities of Alberta.

Using Electronic Referrals to Address Health Disparities and Improve Blood Pressure Control

Introduction

Massachusetts developed and used bidirectional electronic referrals to connect clinical patients across the state to interventions run by community organizations. The objective of our study was to determine whether the use of Massachusetts’s electronic referral system (MA e-Referral) reached racial/ethnic groups experiencing health disparities and whether it was associated with improved health outcomes.

Methods

We assembled encounter-level medical records from September 2013 through June 2017 for patients at Massachusetts clinics funded by the Clinical Community Partnerships for Prevention into 2 cohorts. First, all patients meeting program eligibility guidelines for an e-Referral (N = 21,701) were examined to assess the distribution of e-Referrals among populations facing health disparities; second, a subset of 3,817 people with hypertension were analyzed to detect changes in blood pressure after e-Referral to an evidence-based community intervention.

Results

Non-Hispanic black (OR, 1.4; 95% confidence interval [CI], 1.2–1.6) and Hispanic patients (OR, 1.3; 95% CI, 1.1–1.4) had higher odds than non-Hispanic white patients of being referred electronically. Patients completing their hypertension intervention had 74% (95% CI, 1.2–2.5) higher odds of having an in-control blood pressure reading than patients who were not electronically referred.

Conclusion

Clinical to community linkage to interventions through MA e-Referral reached non-Hispanic black, Hispanic, and Spanish-speaking populations and was associated with improved blood pressure control.

Online referral and immediate appointment selection system empowers families and improves access to public community paediatric clinics

AIM

We aimed to introduce a low-cost combined online referral and immediate appointment selection system (CORIAS) to empower referrers and parents by allowing them to schedule an appointment at a time and location of their choosing in conjunction with the referrer at the time of referral. This was because an unacceptably high rate of reported lost referrals, combined with a high rate of failure to attend initial appointments (FTAs), was noted at a six-site community paediatric clinic service. We aimed to analyse the impact of CORIAS on important outcomes including timely appointment scheduling, attendance, loss of referrals, user acceptance, overall cost and administrative burden.

METHODS

For 3-month periods before and after the implementation of CORIAS, data were collected regarding all new referrals received and initial appointments scheduled, as well as reports of lost referrals. The number of attended initial appointments, FTAs, failures in successfully scheduling appointments, referrer background, CORIAS cost and qualitative feedback received from relevant parties was collated and analysed.

RESULTS

The proportion of referrals reported lost was 6% following the implementation of the combined online system in comparison to 17% pre-implementation. The FTA rate for scheduled initial appointments pre-implementation was 16%; post-implementation, the FTA rate was 9%. Qualitative benefits included a decrease in the administrative burden associated with appointment scheduling and increased service access for culturally and linguistically diverse families.

CONCLUSION

Appropriately designed and implemented novel online systems may improve timely and equitable access to health care by providing secure, reliable pathways for referrers and by empowering and improving communication with patients and families.

Text Mining and Automation for Processing of Patient Referrals

BACKGROUND

Various tasks within health care processes are repetitive and time-consuming, requiring personnel who could be better utilized elsewhere. The task of assigning clinical urgency categories to internal patient referrals is one such case of a time-consuming process, which may be amenable to automation through the application of text mining and natural language processing (NLP) techniques.

OBJECTIVE

This article aims to trial and evaluate a pilot study for the first component of the task-determining reasons for referrals.

METHODS

Text is extracted from scanned patient referrals before being processed to remove nonsensical symbols and identify key information. The processed data are compared against a list of conditions that represent possible reasons for referral. Similarity scores are used as a measure of overlap in terms used in the processed data and the condition list.

RESULTS

This pilot study was successful, and results indicate that it would be valuable for future research to develop a more sophisticated classification model for determining reasons for referrals. Issues encountered in the pilot study and methods of addressing them were outlined and should be of use to researchers working on similar problems.

CONCLUSION

This pilot study successfully demonstrated that there is potential for automating the assignment of reasons for referrals and provides a foundation for further work to build on. This study also outlined a potential application of text mining and NLP to automating a manual task in hospitals to save time of human resources.

Referral system in rural Iran: improvement proposals

Because of insufficient communication between primary health care providers and specialists, which leads to inefficiencies and ineffectiveness in rural population health outcomes, to implement a well-functioning referral system is one of the most important tasks for some countries. Using purposive and snowballing sampling methods, we included health experts, policy-makers, family physicians, clinical specialists, and experts from health insurance organizations in this study according to pre-determined criteria. We recorded all interviews, transcribed and analyzed their content using qualitative methods. We extracted 1,522 individual codes initially. We also collected supplementary data through document review. From reviews and summarizations, four main themes, ten subthemes, and 24 issues emerged from the data. The solutions developed were: care system reform, education system reform, payment system reform, and improves in culture-building and public education. Given the executive experience, the full familiarity, the occupational and geographical diversity of participants, the solutions proposed in this study could positively affect the implementation and improvement of the referral system in Iran. The suggested solutions are complementary to each other and have less interchangeability.

Electronic Sentinel Surveillance of Influenza-like Illness. Experience from a pilot study in New Zealand

BACKGROUND

Electronic reporting of Influenza-like illness (eILI) from primary care was implemented and evaluated in three general medical practices in New Zealand during May to September 2015.

OBJECTIVE

To measure the uptake of eILI and to identify the system's strength and limitations.

METHODS

Analysis of transactional data from the eILI system; comparative study of influenza-like illness cases reported using manual methods and eILI; questionnaire administered to clinical and operational stakeholders.

RESULTS

Over the study period 66% of total ILI cases were reported using eILI. Reporting timeliness improved significantly compared to manual reporting with an average of 24 minutes from submission by the clinician to processing in the national database. Users found the system to be user-friendly.

CONCLUSION

eILI assists clinicians to report ILI cases to public health authorities within a stipulated time period and is associated with faster, more reliable and improved information transfer.

Facilitators and barriers to implementing electronic referral and/or consultation systems: a qualitative study of 16 health organizations

Background

Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery.

Methods

Interviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts.

Results

Electronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows.

Conclusions

eCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1233-1) contains supplementary material, which is available to authorized users.

E-referral Solutions: Successful Experiences, Key Features and Challenges- a Systematic Review

BACKGROUND

around the world health systems constantly face increasing pressures which arise from many factors, such as an ageing population, patients and providers demands for equipment's and services. In order to respond these challenges and reduction of health system's transactional costs, referral solutions are considered as a key factor. This study was carried out to identify referral solutions that have had successes.

METHODS

relevant studies identified using keywords of referrals, consultation, referral system, referral model, referral project, electronic referral, electronic booking, health system, healthcare, health service and medical care. These searches were conducted using PubMed, ProQuest, Google Scholar, Scopus, Emerald, Web of Knowledge, Springer, Science direct, Mosby's index, SID, Medlib and Iran Doc data bases. 4306 initial articles were obtained and refined step by step. Finally, 27 articles met the inclusion criteria.

RESULTS

we identified seventeen e-referral systems developed in UK, Norway, Finland, Netherlands, Denmark, Scotland, New Zealand, Canada, Australia, and U.S. Implemented solutions had variant degrees of successes such as improved access to specialist care, reduced wait times, timeliness and quality of referral communication, accurate health information transfer and integration of health centers and services.

CONCLUSION

each one of referral solutions has both positive and changeable aspects that should be addressed according to sociotechnical conditions. These solutions are mainly formed in a small and localized manner.

Providing specialty consultant expertise to primary care: an expanding spectrum of modalities

In most models of health care delivery, the bulk of services are provided in primary care and there is frequent request for the input of specialty consultants. A critical issue for current and future health care systems is the effective and efficient delivery of specialist expertise for clinicians and patients. Input on a patient's care from specialty consultants usually requires a face-to-face visit between the patient and the consultant. New and complementary models of knowledge sharing have emerged. We describe a framework assessment of a spectrum of knowledge-sharing methods in the context of a patient-centered medical home. This framework is based on our experience in the Veterans Health Administration and a purposive review of the literature. These newer modes of specialty consultation include electronic consultation, secure text messaging, telemedicine of various types, and population preemptive consults. In addition to describing these modes of consultation, our framework points to several important areas in which further research is needed to optimize effectiveness.

Provider-to-provider electronic communication in the era of meaningful use: a review of the evidence

BACKGROUND

Electronic communication between providers occurs daily in clinical practice but has not been well studied.

PURPOSE

To assess the impact of provider-to-provider electronic communication tools on communication and healthcare outcomes through literature review.

DATA SOURCES

Ovid MEDLINE, PubMed, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, and Academic Search Premier.

STUDY SELECTION

Publication in English-language peer-reviewed journals. Studies provided quantitative provider-to-provider communication data, provider satisfaction statistics, or electronic health record (EHR) communication data.

DATA EXTRACTION

Literature review.

DATA SYNTHESIS

Two reviewers conducted the title review to determine eligible studies from initial search results. Three reviewers independently reviewed titles, abstracts, and full text (where appropriate) against inclusion and exclusion criteria.

LIMITATIONS

Small number of eligible studies; few described trial design (20%). Homogeneous provider type (physicians). English-only studies.

CONCLUSIONS

Of 25 included studies, all focused on physicians; most were observational (68%). Most (60%) described electronic specialist referral tools. Although overall use has been measured, there were no studies of the effectiveness of intra-EHR messaging. Literature describing the effectiveness of provider-to-provider electronic communications is sparse and narrow in scope. Complex care, such as that envisioned for the Patient Centered Medical Home, necessitates further research.

Improving the effectiveness of electronic health record-based referral processes

Electronic health records are increasingly being used to facilitate referral communication in the outpatient setting. However, despite support by technology, referral communication between primary care providers and specialists is often unsatisfactory and is unable to eliminate care delays. This may be in part due to lack of attention to how information and communication technology fits within the social environment of health care. Making electronic referral communication effective requires a multifaceted “socio-technical” approach. Using an 8-dimensional socio-technical model for health information technology as a framework, we describe ten recommendations that represent good clinical practices to design, develop, implement, improve, and monitor electronic referral communication in the outpatient setting. These recommendations were developed on the basis of our previous work, current literature, sound clinical practice, and a systems-based approach to understanding and implementing health information technology solutions. Recommendations are relevant to system designers, practicing clinicians, and other stakeholders considering use of electronic health records to support referral communication.