Digitizing the Specialist Referral Process in Carolina

For physician practices that don’t live within the realm of a large health system, meeting Stage 2 of meaningful use’s transitions of care requirements can be challenging. Heck, it can be challenging for the large health systems themselves.

Meaningful use requires eligible professionals (EPs) and eligible hospitals (EHs) to provide a summary-of-care record electronically for 10 percent of patients being transitioned or referred to another provider. A pair of 2014 studies in Health Affairs found that this element, along with the patient engagement requirements, was a major pain point of meaningful use Stage 2 for EPs as well as EHs.

While the patient engagement requirements were whittled down last April from 5 percent of patients needing to view, download, or transmit their health information electronically to one single patient, the summary-of-care measures have stayed the same. The proposed rule for Stage 3 of meaningful use would up the stakes for EPs from 10 percent of patients to an astounding 50 percent of patients.

Lost in Transmission

For independent physician practices like the mid-sized, Raleigh, N.C.-based Wake Internal Medicine, these measures are a huge obstacle to meaningful use attestation. Practices like Wake Internal have traditionally lived in an environment where referrals were made through paper, phone, or fax-based systems. For these guys, achieving the meaningful use metrics wouldn’t be like going from 0 to 60 mph in five seconds, it’d be like having to go from 0 to 100 mph even faster.  

“We never did [electronic] referrals. Everything was done by fax, both incoming and outgoing. If something was missing then we were re-faxing. That inability to track and monitor referrals was a huge problem,” said Matt Johnson, chief administrative officer at Wake Internal.

Another practice in the Tar Heel state, Garner Internal Medicine, a nine-provider practice based in Garner, N.C., had similar issues. “There were too many phone calls, too many faxes, and too much staff time,” said Steven Turner, one of the physician owners of the practice. “We were a middle man between our patients and the specialists, rather than request a referral, we had to do the coordination.”  Like at Wake Internal, Turner couldn’t track a referral once it was made.

Both practices found that faxing referrals to other practices meant information could get lost in transmission. Turner said that it could take months to hear back from a specialist about a referral. Further complicating things, Wake Internal and Garner Internal have different EHR systems than many of their referring partners, making it difficult to send referrals electronically. This lack of interoperability is one of the key reasons transitions of care are a major pain point for practices and hospitals alike.

Electronic Referrals

Wake Internal and Garner Internal got help in the form a cloud-based, EHR-agnostic application. The referral application can be embedded, uploaded, and used right in the EHR, and it allows for real-time communication between providers. Once made, the referral is then tracked from beginning to end, to see whether or not it’s been received, accepted, or denied. Johnson at Wake Internal said the app closes the loop of coordination and “gives appropriate closure,” on patient issues.

“In the old way, [lingering issues] used to slip through cracks. Being smaller, this is important because it means you don’t have to invest hours and babysit those [issues]. [The application] will flag and alert you if the issue hasn’t been followed up on,” said Johnson.

On top of being fast and efficient, Turner said the practice has used it to send referrals to members of the large independent practice association (IPA) it belongs to. In that regard, the application helps the practice validate its status as a clinically integrated group and helps with certification as a Patient-Centered Medical Home. Thus far, it has sent over 10,000 referrals electronically, accounting for 95 percent of all referrals over three years.

In the world of narrow networks, the application allows providers to “prioritize” referrals based on payer requirements, Johnson said. Staying on top of private payer requirements and meaningful use requirements from the federal government is another reason why practices are trying to improve their referral process.

“At least here in the southeast, most of the employers here want very narrow networks and rigid networks … As the networks get more rigid and narrow, it becomes more important for us to make sure we’re compliant with in-network referrals,” Turner said.

For this paradigm shift, physicians may have to learn to change their referral habits, and not automatically help out "their friend down the street," as Johnson put it. But, what they won’t have to do, at least the practitioners in his practice, is use the fax machine.