An electronic referral and consultation system at Zuckerberg San Francisco General has been shown to improve communication between referring and specialty providers, replacing an inefficient paper-based approach.

According to a study published in the August issue of The Joint Commission Journal on Quality and Patient Safety, the infrastructure of specialty referral systems in primary care is “deeply flawed” and paper referral syste “unreliable, wait times can be long, and information flow is limited.” As a result, its authors assert that there is the potential for “safety problems leading to missed and delayed diagnoses.”

However, a web-based referral and consultation system—called eReferral—has been integrated into Zuckerberg San Francisco General’s electronic health record system enabling referring providers to enter relevant clinical information via an online interface, ensuring that referrals do not fall through the cracks and are optimized.

“Historically, especially in the pre-EHR era, primary care physicians referred patients to specialty providers by filling out a piece of paper and faxing it somewhere. It was in no way closed-loop communication, so you never knew what happened with a referral,” says Erika Leemann Price, MD, hospitalist at San Francisco Veterans Affairs Medical Center and primary author of the study.

“Everyone these days is doing or going to electronic referrals as part of an EHR,” adds Leemann Price. “I think the question is how do you make them as safe and efficient as possible for all involved?”

Researchers evaluated communication and referral outcomes for 266 patients referred to the hospital’s gastroenterology clinic through eReferral who were not scheduled for in-person visits. What they found was that, for 68 percent of referrals in the study, patients were not ultimately considered to require in-person gastroenterology clinic appointments or were appropriately redirected for scheduling via other routes.

In addition, about half of these patients (32 percent of all referrals reviewed) were not scheduled because they were resolved via pre-consultation exchange, and very few patients (only 3 percent) received emergency or hospital care while awaiting resolution of gastroenterology referrals.

The eReferral system was originally piloted in 2007 for the gastroenterology clinic and then rolled out for medical and surgical specialties across the healthcare system, according to Leemann Price. Currently, 42 adult and pediatric specialty services—except for two (the burn and infusion clinics)—use the system.

“In our safety-net health system with limited specialist access, we identified few adverse outcomes in electronic referrals of patients not scheduled for in-person gastroenterology visits, and none that were clearly attributable to lapses in the referral process,” conclude the article’s authors.

“Contributors to unintentionally unscheduled referrals included lack of continuing engagement in electronic referrals from providers in non–primary care settings, discontinuity of care in primary care settings, and patient loss to follow-up. As demand for electronic consultation and referral platforms increases, it is vital that close attention be paid to these aspects of pre-consultation exchange to optimize patient safety.”

An editorial in the same issue of The Joint Commission Journal on Quality and Patient Safety, written by Christopher Stille, MD, section head of general academic pediatrics at Children’s Hospital Colorado/University of Colorado School of Medicine, argues that electronic referrals are not just more efficient but are safer.

Stille contends that the eReferral system “enables identification of referrals at risk of being lost to follow-up, something that might be useful even in a non-electronic referral system—this capability alone could significantly enhance patient safety by triggering enhanced follow-up for those patients.”

Further, with EHRs becoming more useful for population health, eReferral systems “may well become more attractive for health systems in the near future.”

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