A Safety-Net System Gains Efficiencies Through 'eReferrals' To Specialists

PRACTICE San Francisco's public safety-net system. WHO AND WHERE At one end, primary care clinicians practicing in five hospital-based, eleven community-based, and ten independent nonprofit community clinics in San Francisco. At the other end, specialist clinicians at San Francisco General Hospital, which provides more than 500,000 outpatient visits annually. CORE INNOVATIONS A new consultation request process, called eReferral, is integrated into the hospital's electronic health record. Clinician-reviewers screen requests to evaluate urgency, choice of specialties, whether sufficient workup information is provided, and whether a specialist needs to see the patient or can guide the primary care clinician through the eReferral system. KEY RESULTS Wait times for nonurgent visits declined in seven of eight medical specialty clinics by up to 90 percent during the first six months of use. Expedited visits accounted for up to a third of all visits in some specialties. The percentage of referrals deemed inappropriate by medical and surgical specialists was cut by more than half. CHALLENGES Access to a common electronic health record and participation by specialists who are salaried, and thus not financially dependent on generating visits, were critical to this program's success-but neither is generally an option in most practice settings. Success also depends on how well reviewers interact with primary care clinicians. The majority of primary care clinicians reported that eReferral improved patient care, but those with poorer access to the electronic health record found it more time-consuming than the previous paper-based system.