Look, No Pen: Managing Referrals Electronically

Look, no pen: managing referrals electronically

Janine Carter

Grampians Health Information & Communications Technology Alliance

Abstract:

This paper describes the process of developing, testing and implementing an electronic referral system in the Grampians region, Victoria. The project, the Referral Information Management System (RIMS) is funded and managed by Grampians Health Information and CommunicationsTechnology Alliance (GHICTA).

The system, which builds on the existing Connecting Care service directory in Victoria, has been developed to provide a more efficient and accurate referral system and avoid duplication of data collection.

The project is led by a health information manager and a project committee has been established to oversee the development and implementation of the system. The committee comprises technical and clinical representatives and reports to the GHICTA Management Committee.

The trial of RIMS was undertaken within the rehabilitation service at Ballarat Health Services over a three month period. A number of planning meetings were held to review referral procedures and identify any change management issues. Staff have been trained in their work groups and an online user manual has been developed for reference. The paper will describe the challenges of training clinical staff and dealing with “occasional” users.

A number of modifications have been made to the system based on informal feedback during and since the trial and a user survey conducted at the conclusion of the trial provided positive feedback and constructive ideas for improvement. The user survey also highlighted the need for further training for some users.

RIMS is now being used in all subacute wards at Ballarat Health Services and plans are in place to deploy it to other hospitals in the Grampians region during 2005 and to implement messaging between other agency systems.

Background: The Grampians Health Information and CommunicationsTechnology Alliance (GHICTA) has undertaken aproject that has seen the development of a patient toservices Referral Information Management System(RIMS) that is being used to replace paper-based referralswithin and between agencies.It is anticipated that the implementation of RIMS will resultin large savings in staff time at the key referralpoints within agencies and deliver more accurate and timely information to receiving agencies with flow onbenefits for service coordination and ultimately patientcare.

RIMS was developed due to ongoing requests from staff to streamline the referral process, particularly for complex rehabilitation patients requiring a range of community services post discharge.

The RIMS project builds on the significant work that has been undertaken in the region with the Connecting Care service directory and referral system. The Connecting Care directory was originally an initiative of a number of health and community service providers in Mildura, Victoria. The project was initially funded by the Federal Governments "Networking the Nation" program, but is now sponsored by participating Primary Care Partnerships (Vic.State). RIMS also utilises the infrastructure being deployed for the implementation of other applications insome of the regions hospitals.

While each agency has its own referral forms, a significant number of government funded agencies have implemented the service coordination tool templates (SCTT) designed by the Department of Human Services (DHS) Victoria to standardise referral information. This has simplified the implementation of RIMS because a number of agencies use the same core set of SCTT forms.

The goals of RIMS include:

• To provide an efficient referral procedure to ensure continuity of care by eliminating the existing cumbersome and time consuming referral procedures.

• To provide an intuitive tool which directs the user to complete the relevant forms and data items for each service provider.

• To provide a system requiring minimal training and computer expertise for its users.

• To provide statistical information about referral volumes and patterns to external and internal agencies.

• To transmission of referrals via various mechanisms and ensuring secure email via Connecting Care.

• To eliminate the need to re-key patient demographic details by interfacing to existing patient management systems.

The system has been field tested at Ballarat Health Services and is being progressively rolled out to healthcareagencies across the Grampians region.

Methods: A RIMS project committee was developed under the auspices of the Grampians Health Information and CommunicationsTechnology Alliance. The committee comprised a project manager, system developer, health information manager, social worker, chief information officer and primary care partnership representative. Other representatives were consulted as required.

The terms of reference of the committee include:

• Defining referral processes and requirements and producing a specification document for an electronic referral system
• Identifying work practice implications
• Managing development of RIMS
• Managing the field test at Ballarat Health Services, including coordination of issues arising during the trial and completion of a user evaluation study at the completion of the pilot
• Providing a report to the GHICTA Management Committee

A prototype was developed and demonstrated to various representatives at Ballarat Health Services to identify any deficiencies and potential improvements and to assess the product against work practice. Following a number of modifications and a training program, RIMS was trialled on the rehabilitation ward at Ballarat Health Services. The rehabilitation ward was chosen specifically due to the number of patients discharged with complex community service programs. Generating paper referrals for patients requiring multiple services was identified as the most cumbersome and inefficient.

The trial was initially scheduled for an eight week period, but due to the Christmas period and low discharge rates, the trial was extended a further four weeks. Six referral agencies were set up with their associated forms. During the trial, users were contacted regularly to identify functional and work practice issues. The project committee continued to meet and discuss user feedback and determine what further development was required. Interestingly the most common request was to include additional service agencies to RIMS so that all referrals could be completed electronically.

During the trial period a regional demonstration was held to gauge acceptance of the electronic referral concept and the RIMS system itself. The demonstration generated significant interest and enthusiasm from agencies across the Grampians region and the potential to streamline referrals was immediately obvious.

A number of agencies have initiated the use of Connecting Care to send referrals via email, so the level of work practice impact is minimal and the culture of electronic referrals is already in place. This has a significant impact on the acceptance of RIMS and presumes a moderate level of computer skills of the referral staff.

AMPIANS HEALTH INFORMATION AND COMMUNI

Results: In addition to informal liaison with the users during the trial a user survey was conducted at the completion of the trial to evaluate user satisfaction and identify the impact of RIMS on the referral process.

During the pilot, 41 patients were entered on to the RIMS system with 156 referrals. Referral forms were set up for District Nursing, Home Help, Home Maintenance, Meals on Wheels, Post Acute Care and equipment providers. Referrals were sent to all of these agencies except post acute care. Most referrals were either emailed or automatically faxed, but some forms were printed and manually faxed due to the need to draw diagrams.

The functionality of RIMS was rated as excellent, good or average, but no respondents rated it as poor or very poor. Positive comments were made about the automatic completion of demographic and episode details from the IBA interface.

One of the users indicated that it was not always clear that all forms had been sent. This issue was resolved by a change to the fax acknowledgement function and further education.

Users requested that additional service providers be added to RIMS so that all referrals could be made electronically. It was also noted that the system would be more effective when all wards and departments across the organisation were using RIMS.

The users rated the screen layout as good or excellent and commented that the screens followed the format of the forms, making the system seem familiar. The screens were also described as easy to understand and follow.

One user noted that some text boxes didn’t allow adequate space for information and did not print all entered data on the Form Summary. This is being investigated by the project team.

Most users had not referred to the user manual since the trial began and most indicated that they were not sure where the manuals were kept. The manual has been updated and made available online via the RIMS help system as well as having hard copies available for training purposes. It was agreed that online manuals are an effective way of ensuring instructions are available from any workstation and that the information is current. This is particularly important in clinical areas due to the number of other manuals and documents stored in these areas and the need to access information quickly.

Although all users had received training, the survey indicated that follow up training sessions were required to reinforce certain functions and highlight the changes made during the pilot.

Lack of available computers was highlighted as an issue, making access to RIMS difficult. Staff were competing for access to computers for RIMS and many other applications, creating frustration and delays.

Most users believed that the RIMS system had improved the process of recording and sending referrals, in particular making it faster and easier. It was acknowledged that being able to view what had been sent and by whom was a significant advantage and avoided duplication. However, it was also noted that the system was reliant on computers and printers being available.

The results of the survey support the verbal feedback received during the trial and confirm the enthusiasm to streamline the referral process by completing all referrals via RIMS.

A number of benefits were identified during the trial, including:

• patient demographic and episode based data are drawn directly from the patient management information systems, thus avoiding the need for duplicate data entry and reducing the risk of transcription errors;

• the system provides functionality to build and use any new referral forms as user needs evolve;

• referrals are stored electronically to enable analysis of referral activity;

• the user interface guides users to complete relevant forms and fields based on the information needs of the receiving service provider;

• service provider directory information can be taken directly from the Connecting Care directory and referral system;

• content of the forms is recorded in a standardised format and all critical information is mandatory

• forms may be emailed to agencies using Public Key Infrastructure (PKI) encryption capability through the Connecting Care system, otherwise they are able to be automatically faxed through a standalone electronic fax management system or printed and manually faxed or mailed out.

TIONS TECHNOLOGY ALLIANCE

Discussion of implications: The project committeeis satisfied that RIMS has achieved its goals and based on the user responses following the field testing, will continue the use of RIMS on the rehabilitation ward and other BHS wards and extend the range of service agencies for which referrals can be sent. Statistical reports have been added to the system and a number of minor functional modifications have been implemented. A project plan is being developed to deploy RIMS to other agencies across the Grampians region during 2005.

Current discussions are being held in relation to business to business referral messages to eliminate the need for service agencies to re-key referral data. Although not in the original scope of the project it is obvious that maximum benefits for the region will only be realised by implementing messaging standards. The Alliance is currently awaiting some direction about the messaging standards definitions before moving towards this model. However, RIMS will continue to be used across the region so that referring agencies can achieve efficiencies in referral processes and continue to refine electronic referral work practices.

Author Details

Name:Janine CARTER

Title:Health Information Systems Project Manager

Organisation:Grampians Health Information & CommunicationsTechnology Alliance

Address:PO Box 577, Ballarat Vic 3353

Phone:03 53206426

Fax:03 53206475

Email:

Janine completed a Bachelor of Applied Science (MRA) at LaTrobeUniversity in 1988 and a Graduate Diploma in Administration at AquinasCollege in 1995.

Positions include various health information management, quality and data management roles at the Queen Elizabeth Centre Ballarat, Ballarat Health Services and the Grampians Health Information and CommunicationsTechnology Alliance. Her current position as RIMS Project Manager includes analysis of information requirements, development of specifications, participation in system design and implementation and training. Janine has been involved in various HIMAA roles including the Victorian Education Subcommittee and the Executive.