NYC takes a bite out of referrals

By Bob Violino
02:22 AM

Finding an easy and efficient way for community physicians to refer patients for clinical services is a high priority for the New York City Health and Hospitals Corp. (HHC), the mammoth hospital and community clinic system serving 1.3 million patients throughout the Big Apple.

Community physicians treat many of the patients HHC serves, yet a large number of providers were unaware of the extensive specialty services HHC provides.

HHC's solution was to create a Webbased information exchange system that allows community-based providers and the public hospitals HHC operates to care for the same patients and in the process improve the coordination, quality and continuity of healthcare.

So far, more than 2,500 private physicians have signed up to be part of the automated system. The system, called HHCAdvantage, accurately tracks every patient who is directed to HHC specialty services, such as radiology, gastroenterology, orthopedics and dermatology.

Clearly, community physicians are using the application: private healthcare providers have made more than 168,000 referrals since the system was launched in May 2008 as part of a community physician program called HHC Connectx.

HHC, a $6.7 billion integrated healthcare delivery system that operates 11 acute-care hospitals, four skilled nursing facilities, six large diagnostic and treatment centers and more than 80 community- based clinics, says it invested $2.5 million to create the application and train community physicians and their staffs to use it.

How it works
Although users of the system don't have to pay for access, the technology has more than paid for itself through increased efficiencies and reduced costs related to referrals, according to Irene Kaufman, senior assistant vice president for medical and professional affairs at HHC.

The automated system uses a customized, Web-based application developed for HHC by Data Industries Ltd., a New York-based company that provides application development and other IT services.

Users from private medical practices, clinics, nursing homes and home care services can access features, including pull down menus that provide information about different healthcare services and specialists. Referring physicians can attach any document or diagnostic test result that will provide the consulting physician with a baseline for treatment.

Patient information that goes over the network is protected by encryption while in transit. The system is in compliance with the security and privacy requirements of HIPAA, Kaufman says.

"Referring physicians only have access to information for the referrals they send," Kaufman said. "The hospitals, on the other hand, have access to all referrals and all pertinent information" about the referred patients. Hospital physicians who use the system have access to the test results and consultation reports, Kaufman said.

HHC trains participating community physicians and staff on how to log onto and use the system, and then they manage their own passwords. Users can generate reports off information they receive via the application, using embedded report management functionality, Kaufman said.

Before the HHCAdvantage system was in place, patients would typically walk into a hospital, receive an initial evaluation and then be sent to a primary care physician at the hospital to be worked up, prior to seeing the specialist they needed to see in the first place, Kaufman said.

It was not an efficient way to get the appropriate care patients needed, she said, and it created an inconvenience for patients who had to be re-evaluated by the hospital-based primary care physician before a referral to a specialty or diagnostic service could be processed.

"The hospital delivery system wasn't really designed to work with patients who were not our patients," Kaufman said. The problem was not limited to inconveniencing patients. There was also the issue of taxing the hospitals' limited resources through avoidable visits to hospital-based doctors.

Adding to the problem, patients often did not bring the necessary information from their providers"such as their clinical history or the reason why they were referred. And patients had to return to the hospital and obtain their medical records in order to share them with their community-based physician.

Paper cuts
HHC tried to address the challenge through a paper-based process that involved having referring physicians fax information about patients to the hospitals. But as the volume of referrals increased, this became time-consuming and inefficient.

The healthcare organization initially launched HHCAdvantage in one of its hospitals as a trial, and the system worked well. After that it was added to all other HHC hospitals, Kaufman said, and use of the system took off.

HHC tries to ensure that physicians who are already part of its healthcare network are aware that the application is available. But in many cases it's the doctors who call the hospitals and request to gain access to the system. Physicians who choose not to use the automated system can still fax in referrals to hospitals, Kaufman said.

HHCAdvantage creates a formal channel of communication between physicians and the hospitals that help coordinate care for shared patients, Kaufman said. Largely because of use of the technology, the number of walk-ins is down to 19 percent in 2010, from 39 percent the year before, she said. HHC has reduced the time it takes to fully process a referral from 3.5 days to 1.3 days.

The system has also helped HHC hospitals eliminate the problem of duplicate care that existed with referrals prior to the implementation. "This system allows us to make the delivery of care more efficient and more coordinated," Kaufman says. The greater efficiency of referrals "is worth the cost of maintaining the program," she said.

HHC plans to integrate HHCAdvantage with the Interboro Regional Health Information Organization (RHIO), a clinical data exchange that serves Queens, northern Brooklyn and surrounding communities in the New York City area. The Interboro RHIO facilitates the sharing of patient information between authorized providers at the point of care.

As RHIOs become more sophisticated and connect a growing number of hospitals and other healthcare facilities, healthcare institutions will be able to collaborate as never before, Kaufman said. In the meantime, the HHC system, "allows us to get everyone on it used to sharing information," she said.

Dr. Sam Bierstock, president and founder of Champions in Healthcare, a Delray Beach, Fla., healthcare technology consulting firm that advised HHC on the implementation, says the system fills a void in the referral process.

"It streamlines the process, markedly increases efficiencies, diminishes unnecessary visits, effectively ensures that patients get to the right place, allows for both the hospital and the referring doctor to track no-shows, and allows processing of large numbers of patients without increasing staffing," Bierstock said. For patients, he says, the benefits include not only greater convenience, but ultimately improved quality of care.

HHCAdvantage by the numbers

  • HHCAdvantage has rolled out to 2,534 community-based providers and 731 community-based practices since it launched in 2008.
  • HHC referral offices processed a total of 105,026 referrals in fiscal year 2010, a 23 percent increase from 2009, averaging 8,752 referrals a month.
  • HHC facilities received 57 percent of their referrals online during fiscal year 2010.
  • Although the volume of consultation reports sent increased by 37 percent in 2010, the average time to send a clinical study report to the referring provider decre