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A new process that could streamline referrals, effectively lighten the load on the ER, and save millions of dollars? While it may sound too good to be true, a new report from the California HealthCare Foundation outlines the benefits of modernizing the referral process by making use of Web-based systems.

Making referrals for specialty or follow-up care is typically a fairly manual process—the originating physician may make a phone call or fax a request to a specialist, but in most cases that's as technologically advanced as it gets. More likely, the patient will receive a slip of paper and instructions to make an appointment for follow-up care. Recently some providers have updated their referral process by making use of Web-based systems designed to help automate and standardize the referral process.

To date, the primary users of so-called e-referring are public health systems and safety net hospitals seeking to reduce overcrowding in the emergency room by referring patients to a primary care provider in the community, according to the report.

"These programs are just beginning. They are growing, but we had to dig pretty deep to find them. We think that this will become more mainstream because it's relatively low cost and low complexity. And, from the patient's perspective, we would hope everyone will eventually do this because it closes a very significant gap in continuity of care," says Jane Metzger, principal of emerging practices at CSC and co-author of the report.

About half of the systems examined by Metzger and Walt Zywiak, principal researcher of emerging practices at CSC, are "homegrown solutions" that were developed to meet the specific needs of the healthcare organization that developed them. At least one of those applications has become available in the commercial market, joining four others already for sale.

E-referring works like this: The originating provider initiates the referral by completing a Web-based request form at the point of care. Patient data is registered, and depending on the complexity of the system, the data is filtered according to insurance coverage, preferred language, even access to public transportation. The referral is sent securely to the participating provider who can then review the referral before scheduling an appointment to ensure that the service is appropriate and all the relevant information is available, according to Metzger and Zywiak.

In addition, an electronic system allows for easier tracking. "One big motivation for the organizations we talked to was being able to institute a process that allows physicians to determine what happened to that referral. There is a clear record of whether the referral was accepted, and if not, why. They can also track whether the appointment was made and kept," says Metzger.

Technologically speaking, getting an e-referral program up and running is pretty simple. Any hospital with a computer and high-speed Internet connection is already half way there. The cost of the application itself varies, and as of yet there is no industry standard for how the software is priced, says Zywiak. "The vendors will either charge a straight subscription fee or a one-time licensing or installation fee, plus subscription or maintenance costs," he says. The prices vary based on vendor. For example, one commercial vendor charges $50,000 per year, per hospital, while another charges a one-time fee of $4,650 per primary care clinic, plus $75 per month for each PCP.

The most trying part of getting an e-referral system up and running will be creating and maintaining participatory agreements with the receiving providers, says Metzger. "There are varying degrees of involvement for the receiving provider, and one of the most challenging aspects of getting a program like this started is determining that participation. I'd tell anyone who is looking to get a program started to look at your network and see what relationships you have in place. Then and only then should you decide what software options you want," she says.

Another downside reported by users, say the report's authors, is the lack of automation in some of the programs. "People want the site applications interfaced with their registration system. If there is a patient you've already seen in the ER, that patient has been registered. If you decide to put in an e-referral, unless you've interfaced your systems, you have to enter all of the information again," says Metzger. This "busywork" has led to some resistance from physicians who do not have the time or inclination to enter the information for a second time. "It's definitely the biggest resentment, why should I have to type all information in?"

And you may be asking yourself, why should I bother? Well, take the case of Aurora Sinai Medical Center—a 195-bed community hospital in Wisconsin. Aurora Sinai was struggling under the burden of trying to care for a large number of uninsured patients coming to the ER for primary care. In an effort to reduce overcrowding, the hospital had implemented a triage program that diverted patients to ambulatory facilities. While the program was successful, turning patients away did nothing for the hospital's image in the community, and staff had no way of following up with patients to ensure they received care.

Hospital administrators wanted to find a way to help staff find and schedule appointments for patients who came to the ER seeking non-urgent care. Enter My Health Direct. For $50,000 per hospital, per year, the program enables staff to schedule an appointment while the patient is still present. Appointments are made using a host of criteria including insurance type, service type, distance from home, preferred language, and need for public transportation. The appointment request is transmitted to the receiving provider, the appointment slot is removed from availability for booking, and the patient is given a printed handout with details of the appointment.

Referral records are kept remotely on the Web database, providing a history of not only that patient's referral record, but a tally of referral volumes by service type, insurance type, etc., according to the report from Metzger and Zywiak.

Since implementing the program, Aurora Sinai has reduced its ER visits from nearly 80,000 a year to 43,000. Overall hospital losses have dropped from almost $25 million annually to "the low single [million] digits," the report says.

"There is plenty of value in thinking about addressing this process. The problem with continuity of care is who really owns it? Whose problem is this? E-referring is one relatively simple way to close a huge gap in the care delivery process," says Metzger.

So what does all this mean for your hospital? Even if you aren't a safety-net hospital looking to reduce overcrowding, the low upfront cost combined with improved tracking ability could make e-referring a very attractive proposition for any provider. And, as more healthcare delivery processes become electronic, your move to a Web-based system could put you a step ahead of where all your peers will eventually be anyway.