Jim Warren National Institute for Health Innovation, University of Auckland (Friday, 9.30, Innovation in Practice 2) Learnings from a recent evaluation of four implementations of electronic referrals (eReferrals) regarding the impact of significant changes in New Zealand health sector that have been enabled by information technology (IT) implementations. Qualitative and quantitative data were collected in the evaluation, including project documentations, system transactional data, and stakeholder interviews. Each project demonstrated different approaches to innovation. The Hutt Valley solution was implemented as a standard IT project, notwithstanding the genuinely pioneering nature of the changes to clinical practice. Northland grew their project organically on a relatively low budget. Canterbury have undertaken the most comprehensive approach combining strong clinical leadership with active participation from Funding and Planning to develop clinical pathways that support the appropriateness and quality of referrals. Auckland has the opportunity of building into their programme the lessons from each of these other implementations. The eReferrals experience proves that they should not be viewed as just a ‘project’ that comes to an end at a set date; it must be an ongoing initiative, with ongoing capacity. Extending this to general innovative health IT initiatives, our conclusion is whatever specific approach is taken, the importance of iterative refinement, user engagement and feedback must be emphasised.

1. Approach to Health Innovation Projects:
Learnings from eReferrals
Jim Warren, Yulong Gu, Karen Day,
Malcolm Pollock, Sue White
The National Institute
Informatics for Health Innovation

2. NIHI commission
• Conducted from Aug 2010 to Jun 2011
• Evaluate electronic referral (eReferral) implementations
– Hutt Valley
– Northland
– Canterbury
– Auckland Metro region (entering pilot operation at time of study)
• Three very different projects (and one still taking shape)
– What do they tell us about the best approach to IT-enabled health
innovation?

3. The Hutt Valley Solution
• Implemented in 2007
• 30 general practices referring in electronically
from Medtech32
• 28 services at Hutt Hospital receiving
eReferrals into Concerto
– 16 service-specific forms, 12 services using a
generic form
• Electronic management of workflow
– GP notified of receipt, triage/decline and FSA
– Hospital can see list of referrals w/ triage pending
– Any authorised user can see content on Concerto
(e.g. from ED)

4. Hutt Valley Uptake
GP referral volume by year (iSoft, Concerto)
• 1000 eReferrals per month in 2008; 1200/mo in 2010
• 56% of total referrals electronic by 2010
• 71% electronic from practices that sent at least one eReferral

5. Hutt Valley Triage Latency
1
0.9
0.8
0.7
Cumulative frequency
0.6
p07
0.5 e08
p08
0.4
e09
0.3 p09
0.2
0.1
0
0 5 10 15 20 25 30
Days
Time from GP letter date to date priority assigned at Hutt Hospital

6. Hutt Valley Upsides and Downsides
• Upsides
– Greater transparency
– Faster turnaround
• Downsides
– IT done once and left
– Some persistent
usability issues
• Slow attachment opening
• Difficulty attaching photos
– Never revisited form
content

7. Northland
• From 2009
• Iterative development of clinically most relevant
forms
– Colorectal, Breast, Diabetes-retinal, Diabetes-
pregnancy, Diabetes-general and, most recently,
Acute referral
• 36 general practices, 29 Whangarei Hospital
services
• From Medtech32, to the door of hospital
(RMS-Lite)

8. Northland Uptake
• Steady
uptake
– Median 26.5
eReferrals
per GP user
in 2010
eReferral volume per month

9. The Canterbury Initiative (CI)
• HealthPathways website initiated in 2009
– Local agreed method for managing a condition (including
referral criteria and fax-able templates)
– Over 300 pathways by May 2011
• eReferral Management System (ERMS) introduced
in July 2010
– 100+ eReferral forms to support HealthPathways
• GP empowerment
– GP triaging for community referred radiology (CRR)
– GPs trained (and paid!) to do skin excisions (GP-to-GP
referral)

10. CI HealthPathway Development &
Dissemination
• HealthPathway definition process
– five 90-minute evening meetings
– GP and specialists have „robust‟ discussion
– The CI facilitator: “… create an environment that enables
change. Relationships provide the vehicle to progress.”
• Regular „Information Evenings‟
• Feedback on declined referrals
– Highly developed in CRR
• Quantum of funding for community based
procedures

12. HealthPathways Hits
• Used during the
weekdays
– With patient, not
as a casual
browse on
weekend
• Stakeholders
indicate
substantial
demand
reduction and
more appropriate Google Analytics report for May 2011
referral HealthPathways viewed
– For dermatology,
US, colonscopy

13. Auckland: IT Project (entering pilot)
• Largest scope
• Greatest process interoperability
• 3 separate phases:
– primary care referrals
– referral workflow (including internal and forwarded
referrals)
– decision support
• hA plan measures a good spectrum of
outcomes
– Acknowledgment and feedback; better tracking;
better information and decisions

14. About eReferrals per se
• Provide transparency
– Status info and rapid feedback
– Further gains with deeper electronic workflow
• Acceptable
– Although not clear that forcing 100% compliance
would work
• Unclear
– Whether to go with many or few forms
– How much the quality of referral data is improved
– Whether clinician effort is increased or decreased

15. What have we learned about the process
• It‟s not like upgrading MS Office
• Plan for feedback and iteration
– Evaluation will identify opportunities for improvement
– No need to do it all in one go
• Take a wide view to achieve transformation
– Don‟t limit horizon to business as usual
– Can achieve more if you change workflow (and let funding
follow activity)
• Disseminate
– Each project should contribute to national learning

16. Questions?
Thank you!
jim@cs.auckland.ac.nz
(CD with full reports from NIHI stand)