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eCHN News

The Growth of eCHN e-Referral

January 2016. On November 15th, 2012, eCHN debuted an innovative new e-Referral system for physicians as the main platform for referring children to SickKids outpatient clinics. SickKids has over 50 outpatient clinics and receives an average of 55,000 referrals annually. The new electronic system automates and streamlines the process by which referrals are made, sparing clinics valuable time and labour involved in processing referrals sent by traditional paper-based means. Over the course of three years, the new system has succeeded in initiating a massive shift in the way referrals to SickKids are made.


SickKids' attempt to enable electronic transmission of referrals had actually begun in 2007 with the implementation of its own online Ambulatory Referral Management System (ARMS). The plan was to strongly encourage the adoption of electronic transmission while continuing to accept paper referrals over a transitional period. The dual options were considered necessary since a survey had found that a considerable portion of physicians' offices did not have internet access. However, the period of transition stretched out as voluntary uptake of the digital option remained at low levels.


When Jennifer Ponsonby assumed  her position as Sick Kids Informatics Nurse/Application Specialist for ARMS four years after its inception, the proportion of referrals made online had remained fixed at around 20%. All the rest, she said, were still being sent by the traditional paper-based routes - mainly fax.


The situation had to change, said Ponsonby. There were multiple problems associated with processing faxed referrals. They could contain incomplete or inaccurate information or be directed to the wrong clinic or fax number. Hand-written notes were often illegible. Sometimes the very reason for the referral to a SickKids clinic had to be carefully re-considered.


As part of a Tertiary Care facility, SickKids outpatient clinics are highly specialized with their own unique requirements for referral information. The description of the patient's medical issue has to be very precisely detailed in order to be properly directed and prioritized by the clinics' rigorous triaging guidelines. Completing and correcting paper referrals to bring them in line with a specific clinic's criteria was inefficient, time-consuming work which often required much back-and forth dialogue between the clinic and the referring health professional.


Paediatrician Mark Feldman who works out of SickKids and St. Joseph's Health Centre was one of the physicians originally invited to participate on the advisory committee for the development of e-Referral. He recalled the way in which eCHN became involved:


"We were interested in finding a technology that could address the problems with paper-based referrals. There were two different electronic systems - there was ARMS which was proving largely successful only internally at SickKids. Then there was this robust mature electronic patient record - eCHN - which had all the information necessary to immediately populate the information fields for referrals. Because it had been deployed at hospitals and private offices, health care professionals already had the experience of accessing SickKids electronically. So it just made sense to merge the technologies together."


Andrew Szende, eCHN's Founding CEO commented, “We were pleased to see an opportunity for the clinicians to make better and further use of the data that was available through our consolidated patient record. We worked with the SickKids folks and with the clinicians to make sure that the solution was as user-friendly as possible.”


When the new e-Referral system was ready to go in early 2012, the decision was made to implement a complete changeover this time. "It was put to me," explained Jennifer Ponsonby, "that we needed to draw a line in the sand, we needed to push to make referrals electronic. The goal at that point was to reverse the statistics - to have 80% submitted electronically and 20% by fax."


A short pilot project with four SickKids clinics was used to fine-tune the system before it was promoted to all the clinics and the Emergency department. On November 15th, eCHN e-Referral became the officially designated, mandatory system for making referrals to SickKids outpatient clinics.


If a referral was faxed, explained Ponsonby, it was sent back with the request that it be re-sent electronically and with instructions on how to proceed via eCHN. There were exceptions made, on a case-by-case basis -  for example, if the referral was urgent, or if it came from a physician without internet access who was close to retirement. "For the first six months", said Ponsonby, "we were very patient".


The growth in the use of the eCHN e-Referral system was slow in the first year, hovering in the 28% range. However, by 2014 the numbers were  climbing significantly and in 2015, the goal of completely reversing the ratio between electronic  and paper-based referrals was achieved. Now, 80% were being sent electronically via eCHN e-Referral and 20% by paper. By the summer of 2015, with the total number of referrals holding steady in the 50 to 55 thousand range, the ratio was tilting even further - 85% digital vs. 15%  paper.


Dr. Feldman admitted there were some growing pains while the transition was underway but said there are so many advantages to the new system - "Now I think everyone's finding it incredibly helpful". He himself uses the system whenever he needs to make a referral to SickKids, or the nurse he works with does. There is the option to delegate a staff member to make the referral.


He pointed to the ease with which a referral can be made and the resulting gain in clarity. "Now there are drop-boxes with choices that each sub-specialty has customized for the information it needs. There's an opportunity for decision tools. The reason for the referral is clearer. They can triage the referral more appropriately, which is probably a much better use of health care dollars."


Equally important, he said, is the much greater continuity of information about the referral available to referring health professionals. "Has the referral been accepted, has it been triaged-out, has the appointment with the patient been made, has the patient been seen? They can go on-line and instantly update the status of their referral, which was very difficult to do with a paper-based system. You'd phone the clinic and stay on hold or leave a message... It was really hard to get that information quickly."


With ongoing feedback from the advisory committee of health professionals, eCHN and SickKids continue to work on improving the e-Referral system. One of the proposals being considered is the extension of the system to sub-specialists in the community who have not made the referral but are also involved in the specific patient's care. Rather than having to wait to obtain information such as blood test results until after the patient visit to SickKids has occurred, they would have access, like the referring physician, to the different stages of the referral in progress.


Another proposal focuses on the lack of integration among the many different Electronic Medical Record (EMR) systems being used in community physicians' offices. Offered by multiple vendors, these systems do not speak to each other nor do they interface with eCHN.


"I understand that this is on the horizon," said Dr. Feldman. "There's a desire on the part of SickKids to look to supporting a technology that community-based paediatricians could use in their office. eCHN has developed a particular expertise in adapting their system to multiple disparate systems. They're good at that. I would definitely support the exploration of a single EMR to be used by community offices - with a view towards connecting it to eCHN."


The future holds the promise of further technical enhancements that will make the system ever more seamless. In the meantime, there is ample satisfaction to be savoured among the champions of e-Referral that the multi-challenged transformation from paper to electronic referrals has been largely achieved.


 "We still have work to do", said Jennifer Ponsonby "but we're definitely very happy." 


Added eCHN's Founding CEO, Andrew Szende, “I am looking forward to the day when this type of electronic referral will be available to paediatric clinics not only at SickKids but at all eCHN member hospitals.”

Photo above left: eCHN Senior Managers engaged in their weekly review.

Photo above right: Members of MED team with eCHN Founding CEO pay tribute to standardization guru, Dr. Gilbert Hill (second from right).