E-referrals: improving the routine interspecialty inpatient referral system

Abstract

Interspecialty referrals are an essential part of most inpatient stays. With over 130 referrals occurring per week at the Royal Devon and Exeter Hospital, the process must be efficient and safe. The current paper-based ’white card' system was felt to be inefficient, and a Trust incident highlighted patient safety concerns. Questionnaires reinforced the need for improvement, with concerns such as a lack of referral traceability and delays in the referral delivery due to workload. The aims of the project were to improve patient safety and junior doctor efficiency in the referral process. Through appreciative enquiry and the PDSA (Plan-Do-Study-Act) model, an electronic referral system was developed, piloted within two specialties and later expanded to others with improvements made along the way based on user feedback. The system includes novel features including specialties ’acknowledging' a referral to allow referral progress to be tracked. The system stores all referrals, creating a fully auditable inpatient referral pathway. Qualitative data indicated improvement to patient safety and user experience (n=31). Timings for referrals were measured over a 6-month period; referrals became faster with the electronic system, with average time from decision to refer to referral submission improving from 2.1 hours to 1.9 hours, with a noted statistically significant improvement in timings on a statistical process control chart. An unexpected benefit was that patients were also reviewed faster by specialties. Measuring these changes presented a significant challenge due to the complexity of the referral process, and this was a big limitation. Overall, the re-design of a paper-based referral system into an electronic system has been proven to be more efficient and felt to be safer for patients. This is a sustainable change which is being rolled out Trust-wide. We hope that the reporting of this project will help others considering reviewing their inpatient referral pathways.

Improving medical consults for surgical inpatients: a quality improvement project using an e-referral system linked to clinical pathways

“…Statistical power may have been lacking for clinical outcomes but the limitations of post hoc power calculations are well documented 18. The improvement in staff experience is similar to that observed in the study by Shephard et al 13…”

“…Inpatient e-referrals are growing in use but the evidence base is limited to a handful of studies, mostly designed to assist resource allocation for busy departments 10–12. A recent quality improvement study comparing inpatient e-referrals with paper-based referrals showed improved staff-reported patient safety, user experience and statistically significant reductions in referral time (time from decision to refer to referral submission) and review time (time from referral submission to review) 13…”

Factors affecting the successful implementation of the referral system

“…According to the obtained evidence, implementation of the electronic referral system,[ 10 11 12 ] the relationship between health centers and hospitals,[ 2 ] gatekeeping management of Referral system,[ 13 ] and patient-centered communication[ 14 ] are among the factors that result in increasing the efficiency of the referral system. Factors that increase the efficacy of the referral system include the implementation of the electronic referral system,[ 15 ] the use of standard templates for referral letters,[ 16 ] and increasing access through communication and transportation systems. [ 17 ] Also, the factors that ended up with increasing the quality of referral system services are the implementation of electronic referral system,[ 12 18 ] coordination among the three levels of referral system,[ 19 ] continuing education of general practitioners,[ 20 ] increasing access through communication and transportation systems,[ 17 ] and possible modification of referral instructions.…”

Practice and Opinion of Doctors in Primary Health Care Centers Toward Referral System: Samples from Nine Governorates in Iraq

“…Electronic healthcare information systems worldwide offers many benefits to all healthcare providers concerned with patient management, including real-time queries for medical and personal information, and therefore easier feedback and follow-up. They also reduce the meantime for referral decision and reception of feedback (12,20,(26)(27)(28).…”