Humboldt County: Tracking Referrals through an Electronic Referral System
Dr. Alan Glaseroff is the Chief Medical Officer for the Humboldt Independent Practice Association (IPA) in Northern California. The IPA has a track record of implementing successful quality improvement initiatives including their Humboldt Diabetes Project, which has demonstrated improved health outcomes for their patients. The IPA utilizes technology solutions including a chronic disease registry that contains 93 percent of all patients with diabetes in Humboldt County. The registry is expanding to include several chronic conditions to track preventive screenings and report office-based metrics, including BMI and blood pressure. A few practices have also launched electronic prescribing via a stand-alone free product (eRx) although the majority of prescribing occurs via electronic health records (EHRs).
 
AccountabilityDr. Glaseroff acknowledges that each platform (EHR, registry, eRx, etc.) introduces necessary reconfiguration in the clinic’s workflow; additionally, avoiding duplicate data entry (EHR, registry) proved of critical importance to maintain the willingness to use shared platforms not included in office-held solutions (exporting data from EHR to populate the community-wide applications).
 
Humboldt's IPA has recently introduced an electronic referral (e-referral) system, which was purchased and implemented using grant funding. After reviewing e-referral vendor options, the IPA adopted the Internet Referral Information System (IRIS), first used at Cook County Hospital in Chicago. The technology’s design is often compared to how FedEx tracks its packages, because if a step within the process does not take place, the system sends an automatic alert. All referral steps, from beginning to end, are tracked by a referral coordinator.
 
The referral coordinator is a clerical position in Dr. Glaseroff’s practice that also serves as the practice receptionist. Through her pro-active follow-through, the practice has been able to accomplish a 100 percent completion rate for mammography referrals.
 
The referral coordinator monitors reports generated by the e-referral system. Examples of these reports include referral appointments that have been missed by patients or consultative reports that have not yet been received. The referral coordinator follows up on these referral problems and takes action. The referral coordinator is also accountable for ensuring that information between the primary care practice and specialist’s office is exchanged.
 
The e-referral system incorporates rules analogous to referral guidelines often included in service agreements. The goals of the rules are to:
  • Increase the appropriateness of referrals.
  • Prompt preparatory work that should be completed prior to the specialist appointment.
  • Establish “rules of engagement” for specialty referral (PCP-specialist compact).
ConnectivityIRIS produces a set of instructions for referrals to specialists and for procedures. For example, a referral for a CT scan with contrast automatically prompts an alert to the primary care clinic to have the patient complete a serum creatinine test within the month prior to the CT scan. Adherence to these referral guidelines are monitored by the referral coordinator via protocol. While there is significant variation in how individual clinicians use IRIS, Dr. Glaseroff believes that the optimal approach is to have the clinician start the process electronically with the patient in the room. The patient receives “patient instructions” that outline next steps. Within 24 hours, the referral coordinator enters the patient’s demographic and insurance information into the e-referral system along with key clinical information (including lab test results) from the patient’s chart.
 
 
To support the roll-out of e-referral across sites, the IPA hired a full-time coordinator who works with clinics to implement the system. The coordinator is able to troubleshoot problems and continually monitor the system. She was involved in training all of the referral coordinators at each of the clinics and developed their User Guide. She also maintains a website with the latest information [contact Humboldt County for details].  
  
Dr. Glaseroff believes that this system currently improves patient care because it enables primary care practices to systematically track their patients’ referrals so that fewer patients slip through the cracks. With e-referral, information is not lost and the patient’s primary care provider is kept informed, promoting the “medical home” concept. Dr. Glaseroff believes that, “IRIS will serve as the platform to transform individual isolated medical homes into true medical neighborhoods.”