Referral Efficiency for Veterans with Osteoarthritis: A Quality Improvement Project

Management of osteoarthritis, a common disease among veterans, includes referrals to orthopedic specialists. This requires an effective referral system. The aim of this study was to evaluate a quality improvement project addressing inefficiencies in the osteoarthritis referral process between primary care providers and orthopedic specialists. A pre- and post-intervention evaluation using medical record review and provider surveys was conducted to measure the process improvement of a primary care to orthopedic referral template. There was a 3.5% increase in the referral acceptance rate following the intervention. In addition, primary care providers perceived that role clarity and perception on making referrals had significantly improved. The largest perceived improved change among orthopedic specialists was in communication. A simple process change, such as improving the referral template, can help with communication, data transfer, and referral acceptance rates between primary care providers and orthopedic specialists. This in turn will benefit the large population of veterans needing orthopedic referrals for management of osteoarthritis.

A Data-Driven Algorithm to Recommend Initial Clinical Workup for Outpatient Specialty Referral: Algorithm Development and Validation Using Electronic Health Record Data and Expert Surveys

BACKGROUND

Millions of people have limited access to specialty care. The problem is exacerbated by ineffective specialty visits due to incomplete prereferral workup, leading to delays in diagnosis and treatment. Existing processes to guide prereferral diagnostic workup are labor-intensive (ie, building a consensus guideline between primary care doctors and specialists) and require the availability of the specialists (ie, electronic consultation).

OBJECTIVE

Using pediatric endocrinology as an example, we develop a recommender algorithm to anticipate patients' initial workup needs at the time of specialty referral and compare it to a reference benchmark using the most common workup orders. We also evaluate the clinical appropriateness of the algorithm recommendations.

METHODS

Electronic health record data were extracted from 3424 pediatric patients with new outpatient endocrinology referrals at an academic institution from 2015 to 2020. Using item co-occurrence statistics, we predicted the initial workup orders that would be entered by specialists and assessed the recommender's performance in a holdout data set based on what the specialists actually ordered. We surveyed endocrinologists to assess the clinical appropriateness of the predicted orders and to understand the initial workup process.

RESULTS

Specialists (n=12) indicated that <50% of new patient referrals arrive with complete initial workup for common referral reasons. The algorithm achieved an area under the receiver operating characteristic curve of 0.95 (95% CI 0.95-0.96). Compared to a reference benchmark using the most common orders, precision and recall improved from 37% to 48% (P<.001) and from 27% to 39% (P<.001) for the top 4 recommendations, respectively. The top 4 recommendations generated for common referral conditions (abnormal thyroid studies, obesity, amenorrhea) were considered clinically appropriate the majority of the time by specialists surveyed and practice guidelines reviewed.

CONCLUSIONS

 An item association-based recommender algorithm can predict appropriate specialists' workup orders with high discriminatory accuracy. This could support future clinical decision support tools to increase effectiveness and access to specialty referrals. Our study demonstrates important first steps toward a data-driven paradigm for outpatient specialty consultation with a tier of automated recommendations that proactively enable initial workup that would otherwise be delayed by awaiting an in-person visit.

Specialty Physician Designation in Referrals from a Vertically Integrated PCMH

Introduction:

Primary care referrals to specialty physicians once relied upon the medical skill of the specialist, the quality of past communication, and previous consultative experiences. As health systems vertically integrate, patterns of specialty physician referral designation are not known.

Methods:

This cross-sectional study from a patient-centered medical home (PCMH) evaluated the proportion of referrals with named specialists. All outpatient specialty referrals from the PCMH between July and December of 2014 were eligible for inclusion, and 410 patients were randomly selected for chart review. The outcome of interest was specialty physician designation. Other variables of interest included PCMH provider experience, the reason for referral, and time to specialty visit. Univariate analysis was performed with Fisher exact tests.

Results:

Of 410 specialty referrals, 43.7% were made to medical specialties, 41.7% to surgical specialties, and 14.6% to ancillary specialties. Resident physicians placed 224 referrals (54.6%), faculty physicians ordered 155 (37.8%), and advanced practice providers ordered 31 (7.6%). Only 11.2% of the specialty referral orders designated a specific physician. No differences appeared in the reason for referral, the referral destination, the proportion of visits scheduled and attended, or the time to schedule between those referrals with and without specialty physician designation. Faculty physicians identified a specific specialist in 21.4% of referrals compared to residents doing so in 4.9% (P < .0001).

Conclusion:

Patient-centered medical home referrals named a specific specialty physician infrequently, suggesting a shift from the historical reliance on the individual characteristics of the specialist in the referral process.

Comparative usability evaluation of consultation order templates in a simulated primary care environment

Communication breakdowns in the referral process negatively impact clinical workflow and patient safety. There is a lack of evidence demonstrating the impact of published design recommendations addressing contributing issues with consultation order templates. This study translated the recommendations into a computer-based prototype and conducted a comparative usability evaluation. With a scenario-based simulation, 30 clinicians (referrers) participated in a within-group, counterbalanced experiment comparing the prototype with their present electronic order entry system. The prototype significantly increased satisfaction (Cohen's d = 1.80, 95% CI [1.19, 2.41], p < .001), and required significantly less mental effort (d = 0.67 [0.14, 1.20], p < .001). Regarding efficiency, the prototype required significantly fewer mouse clicks (mean difference = 29 clicks, p < .001). Although overall task time did not differ significantly (d = -0.05 [-0.56, 0.47]), the prototype significantly quickened identification of the appropriate specialty clinic (mean difference = 12 s, d = 0.98 [0.43, 1.52], p < .001). The experimental evidence demonstrated that clinician-centered interfaces significantly improved system usability during ordering of consultations.

Evaluation of specialist referrals at a rural health care clinic

PURPOSE

Transition to a value-based care system involves reducing costs improving population health and enhancing the patient experience. Many rural hospitals must rely on specialist referrals because of a lack of an internal system of specialists on staff. This evaluation of the existing specialist referrals from primary care was conducted to better understand and improve the referral process and address costs, population health, and the patient experience.

DATA SOURCES

A 6-month retrospective chart review was conducted to evaluate quality and outcomes of specialty referrals submitted by 10 primary care providers. During a 6-month period in 2015, there was a total of 13,601 primary care patient visits and 3814 referrals, a referral rate of approximately 27%.

CONCLUSIONS

The most striking result of this review was that nearly 50% of referred patients were not making the prescribed specialist appointment. Rather than finding a large number of unnecessary referrals, we found overall referral rates higher than expected, and a large percentage of our patients were not completing their referrals.

IMPLICATIONS FOR PRACTICE

The data and patterns emerging from this investigation would guide the development of referral protocols for a newly formed accountable care organization and lead to further quality improvement projects: a LEAN effort, dissemination of results to clinical and executive staff, protocols for orthopedic and neurosurgical referrals, and recommendations for future process improvements.

A multifaceted approach to improving the quality of ENT Emergency Clinic referrals

It is imperative that primary care referrals are directed to the appropriate secondary care service. Patients presenting to a primary care physician with ENT conditions may require review in an Emergency Clinic. The latter clinics provide patients with rapid access to secondary care, for urgent, yet non-life-threatening conditions. In our department, we noticed that patients with conditions inappropriate to the capabilities of the Clinic were being booked in or reviewed too late; thus causing wasted journeys for the patient. We conducted a Quality Improvement Project to improve the efficiency of the referral process. A prospective evaluation of referrals was collected continuously over a two-month period. Overall, 5 domains were deemed crucial to enable timely and accurate booking of patients to clinic: booking date, urgency, legibility, patient identification and appropriateness. Our proposed standard set for this project was 100% compliance over the 5 domains. Three separate interventions were instigated following the first cycle. The main components of the intervention were the phased development of an electronic referral system and an educational initiative for junior doctors. 20 referral forms were analysed during the initial 3-week period. No referrals met the recommended overall compliance standard of 100% (mean number of domains achieved: 3.38; standard deviation (SD): 0.637). Legibility and patient information were included in 21% and 30% of referrals, respectively. There was a trend of improvement following initiation of interventions. The mean number of domains achieved was 4.27 (SD 0.647; n=13) in the second data collection period, 4.53 (SD 0.514; n=16) in the third, and 4.75 (SD 0.452; n=24) in the fourth. Using linear regression, this change demonstrates a statistically significant improvement (p<0.001). An e-Proforma referral system represents a safe and efficient communication technology. When implementing policy change, it is crucial to acquire managerial and consultant support.

ASSESSING REFERRALS AND IMPROVING INFORMATION AVAILABILITY FOR CONSULTATIONS IN AN ACADEMIC ENDOCRINOLOGY CLINIC

OBJECTIVE

Outpatient specialty consultations rely on the timeliness and completeness of referral information to facilitate a valuable patient-specialist interaction. This project aimed to increase essential diagnostic information availability at the initial consultation for patients referred for common endocrine conditions frequently lacking such data-diabetes mellitus, thyroid nodule, thyrotoxicosis, and hypercalcemia.

METHODS

At an endocrinology clinic at an academic medical center in rural New England, providers see several thousand new patients annually, the majority of whom are referred by providers external to the clinic's healthcare system. Through consensus, endocrinology clinic providers agreed on the two or three data elements essential for a meaningful initial consultation for each. A quality improvement team employed a planned series of interventions based on previously published methods and an innovative approach: dissemination of a referral guideline, an assessment of referral adequacy in the endocrinology clinic workflow, coupled with focused requests for missing items, and a pre-visit lab appointment.

RESULTS

Between April 2015 and March 2016, 762 referrals were reviewed. At baseline for the four conditions, referrals contained all essential elements only 27.5% (22 of 80) of the time. Over a 7-month period, the team implemented the interventions, with subsequent referrals containing all essential elements increasing to 75.5% (P<.0001), largely attributable to the pre-visit lab appointment.

CONCLUSION

Incoming referrals that lack essential information are a significant problem in specialty care and may adversely affect patient experience, provider satisfaction, and clinic efficiency. Improvement may require innovative approaches, such as the potentially transferable and generalizable ones employed here.

ABBREVIATIONS

DHMC = Dartmouth-Hitchcock Medical Center EHR = electronic health record PDSA = Plan-Do-Study-Act.

Evaluating the referral preferences and consultation requests of primary care physicians with otolaryngology - head and neck surgery

Background

No literature exists which examines referral preferences to, or the consultation process with, Otolaryngology. In a recent Canadian Medical Association nation-wide survey of General Practitioners and Family Physicians, Otolaryngology was listed as the second-most problematic specialty for referrals. The purpose of this study was to learn about and improve upon the referral process between primary care physicians (PCPs) and Otolaryngology at an academic centre in Southwestern Ontario.

Methods

PCPs who actively refer patients to Otolaryngology within the catchment area of Western University were asked to complete a short paper-based questionnaire. Data was analyzed using descriptive statistics.

Results

A total of 50 PCPs were surveyed. Subspecialty influenced 90.0 % of the referrals made. Specialist wait times altered 58.0 % of referrals. All PCPs preferred to communicate via fax. Half of those surveyed wanted clinical notes from every encounter. Seventy-four percent of respondents wanted inappropriate referrals forwarded to the proper specialist automatically. Twenty-two percent of those surveyed were satisfied with current wait times. A central referral system was favored by 74 % of PCPs.

Conclusion

Improvements could help streamline the referral and consultation practices with Otolaryngology in Southwestern Ontario. A central referral system and reduction in the frequency of consultative reports can be considered.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-015-0114-2) contains supplementary material, which is available to authorized users.