Bridging the fax gap: The push for a seamless referral system

The referral process in Canada’s healthcare system is variously described as a disaster by OMA president Dr. Dominik Nowak—and a glass half full by Canada Health Infoway’s Dr. Rashaad Bhyat. Both are family doctors intimately aware of the headaches associated with reliance on fax machines, but there is hope for the future.An eReferral network that is supported by the eHealth Centre of Excellence in Kitchener, Ont., now boasts 9,916 family physicians and nurse practitioners, 2,292 specialists and 2,877 others, including optometrists, physician assistants and residents, who have collectively used it to send three million referrals. According to Dr. Mohamed Alarakhia, the centre’s CEO, the technology is also being used by 95% of Nova Scotia doctors and is currently being implemented in British Columbia, in both cases through provincially sanctioned programs. Having more than 15,000 Ontario doctors on eReferral sounds impressive but, in reality, many referrals are still being sent by fax. If a family doctor on eReferral somewhere in Ontario needs to refer a patient to an endocrinologist and there are no endocrinologists in the area on the system, the family doctor has no other choice but to send it via fax. Similarly, if there are no family doctors signed up in the area, or very few, the endocrinologist has no incentive to get on board.Read: The referral dilemma“Our eReferral network started out as a very local, regional service and it’s slowly expanding provincially and nationally, but we’re now on the exponential part of the curve,” said Dr. Alarakhia. Adoption is maximized, he acknowledges when both sending and receiving physicians are brought on at the same time in a region.The mechanicsFamily physicians and nurse practitioners, naturally enough, send a referral directly from their EMR. “The specialist receives it electronically and is able to triage it,” said Dr. Alarakhia. “The patient gets notification that he’s been triaged and gets an appointment online. He then confirms the appointment and receives a reminder with all of the instructions, so it’s end to end. There’s no paper involved.”The system is compatible with 90% of the EMRs, “so you don’t need to enter patient information because everything is there. You can attach things from your medical record and it all flows through,” explained Dr. Alarakhia.” Physicians with an EMR that can’t accommodate an integration are able to leverage the software itself. They would have to copy and paste details from one system to the other.eReferral users in Ontario have access to a provincial directory of specialists that includes wait times, sub-specialties and calculated distance from the patient’s residence. The list also indicates if the specialist is on eReferral. Doctor and patient review the options and the patient decides where to go based on the wait time and distance from his home. “I click on the patient’s preferred specialist and both the patient’s information and my information as a clinician are automatically transferred into the form. I say, ‘This patient has uncontrolled diabetes. Please see.’ I click send and it’s gone.”If Dr. Alarakhia, who practises in Waterloo, Ont. has a patient attending university in Ottawa and needs a referral to a specialist there, it’s no problem because the list of specialists comes from a province-wide directory.Sending physicians also receive status updates in their EMRs, so “It’s no longer a black box,” said Dr. Alarakhia. “I know it’s being triaged. I know when an appointment has been made. I know the patient has confirmed the appointment.”Impatient for changeStill, the glass half full status of eReferral still leaves a large number of doctors in Ontario, including OMA president Dominik Nowak, frustrated and impatient for change. “In my work as a family physician,” he said, “I see the pain that doctors have to put up with. In one case, for example, it took me eight months, contacts with five different specialists and numerous faxes back and forth to process a referral for a fairly urgent issue.”Faxing referrals, he claims, contributes to the 19 hours a week of unnecessary paperwork and administration that doctors have to endure.Dr. Nowak complains about the current patchwork of electronic referral systems in certain communities and for certain specialties like low back pain. The missing link, he claims, is a central intake system. “Right now, it’s on the shoulders of doctors’ offices to navigate which specialist or imaging site to send a referral to. A central intake would allow us to send it and forget it.”While acknowledging that early work is under way to reform the referral process, he worries that “we will end up with several versions of electronic referral and intake systems all requiring different logins and passwords.”Central intake programsDr. Alarakhia agrees there is a role for central intake programs, especially for services with long wait times, and that there should be more of them, but doesn’t think everything needs to be centralized.Unfortunately, a study that surveyed family physicians in Toronto found that there was a low awareness of centralized intake services because they are poorly promoted and there are so many of them. Lead author Dr. Tara Kiran, a family doctor at St. Michael’s Hospital Academic Family Health Team, complained that “there isn’t one place where you can easily find the information you need.”Another challenge slowing the expansion of eReferral solutions across the county, notes Dr. Rashaad Bhyat of Infoway, is the lack of interoperability. Infoway’s project Halo is tasked with working with all of the provinces and territories, as well as all of the EMR vendors to standardize using a FHIR-based communication interface.The eHealth Centre of Excellence eReferral network has managed to work with most EMRs, but in some cases through customized integrations. “Doing things in a standardized way is important,” agreed Dr. Alarakhia, “because you want to make it easy. We need to move forward with standardized FHIR-based integrations for all of these systems.”The eHealth Centre of Excellence organizes webinars and presentations to promote signups and relies on clinician champions to extol the benefits of eReferral. The onboarding process, said Dr. Alarakhia, is fairly straightforward and support is available from the Centre’s change management team. Ontario’s size and the large number of practising physicians in the province has slowed uptake, but “Ontario has now made this a very high priority, so I think scale and spread will accelerate soon,” said Dr. Alarakhia.Though some clinicians are fine with using faxes for those physicians anxious to get rid of their fax machines can only hope he’s right.

Bridging the fax gap: The push for a seamless referral system

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