Gary McWilliams, MD

University Health System uses referral-automation and decision-support software to reduce wait times for specialty care.

To give the uninsured in the area access to affordable, high-quality healthcare services, San Antonio’s University Health System, an academic medical center that offers a full range of medical services for patients in a 22-county area of south Texas, established the CareLink financial assistance program. Families have monthly payment plans based on their family size and income, for which they may receive services through University Health System. Each patient is assigned to a primary care physician (PCP), who serves as his or her medical home. The successful program currently has more than 57,000 participants, who made more than 189,000 office visits to a PCP in 2011.

Success was not without its own challenges, however. With the advent of the program, PCP referrals rapidly escalated, which had a corresponding impact on specialty referrals. Waits to see specialists for non-urgent appointments lengthened considerably – up to six months in certain cases – as specialists’ calendars became increasingly booked. Compounding the volume issue was the fact that referral requirements lacked clarity, so that many specialist referrals were inappropriate. Specialists began reviewing referrals carefully, even discussing them with colleagues, to make sure they should see the patient, eating up valuable, billable time even if ultimately they didn’t see the patient. Referrals to non-network providers went up as well, driving up costs.

University Health System leadership realized that something needed to be done, and quickly, to make sure guidelines for referrals were clear and referrals were ultimately appropriate, both of which would help specialists maintain more manageable schedules. This, in turn, would reduce the wait times that were not only causing frustration for caregivers and patients but also having an impact on care quality.

A common online language improves communication, efficiency
The health system found a solution in CareEnhance Review Manager, a browser-based, interactive software from McKesson that automates care-review processes, such as referrals. Review Manager uses McKesson’s InterQual decision-support criteria – in this instance, InterQual Care Planning Criteria for Specialty Referral – to guide decision making according to evidenced-based medical standards, helping improve consistency among reviewers and making review processes more efficient. Both the primary care providers and the specialists quickly saw the value in using an established set of guidelines to facilitate the referral process.

University Health System uses Review Manager to make the InterQual Criteria available directly via its website home page for its provider network, including PCPs, specialists and administrators, giving everyone a uniform understanding of referral requirements. The health system delivers care to 200,000 unique individuals each year, utilizing more than 100 PCPs and 900 full- and part-time specialists. To encourage use, PCPs were assured that if they used the criteria, their patients would quickly get to the specialists they needed. If they didn’t, referral may not be timely, if it occurred at all. To the specialists, the message was, “If we ensure that the patients meet these criteria, you will stop reviewing all referrals and just start booking patients.”

According to Gary McWilliams, M.D., executive vice president and chief ambulatory services officer at University Health System, the combination of software and referral criteria have been a win-win for both primary care physicians and specialists. “We’ve had buy-in from both sides,” he says. “PCPs understand that if they follow the criteria, their patients will be able to see specialists in a timely manner. Cardiologists are happy because they’re seeing patients who really needed to be seen, not wasting time on those who don’t.” Specialists are also spending less time assessing referrals and more time performing billable services.

PCPs can review the criteria before submitting referral requests to the hospital’s Access Plus department, which is responsible for referral screenings. If a referral does not meet requirements, an Access Plus staff member sends it back to the PCP along with the section of the criteria that explains why the referral was denied.

“Before this, the reason referrals were denied often wasn’t clear, which led to frustration and delays. Now, with the criteria online, there is no confusion about what makes a good referral,” McWilliams explains.

For this approach to achieve the success it has, physicians had to feel comfortable with the quality of the content. McWilliams has heard from his colleagues that they have a lot of trust and faith in InterQual: “The specialists think the criteria are reasonable,” he says, “which helps build credibility with the PCPs.” The criteria have also become a useful teaching tool for residents encountering a complex set of conditions for the first time, an unexpected benefit to the health system.

In addition, specialists can modify the referral criteria according to their preferences or the needs of their practices, flexibility that helps with physician buy-in because they view the criteria partially as their product.

Measurable benefits
This revised referral process has engendered better alignment and good will between physicians and specialists, fueled by smoother interactions and greater understanding of why referral decisions are made. And ultimately, all providers are now seeing the right patients sooner. The process was initially rolled out to cardiologists, with impressive results. Some specific benefits include the following:

Although the number of cardiology staff has remained constant, the wait time to see a cardiologist has decreased dramatically: from an average of 134 days in 2005 down to virtually same-day service in 2009. As of January 2012, the wait time for a routine referral to cardiology is only two days.

Out-of-network referrals have been nearly eliminated. The number of patients referred to outside cardiologists dropped 98% from 801 in 2005 down to only 22 in 2009, while the total number of patients was practically unchanged. During 2011, only three referrals were made to outside cardiologists, all for special-needs situations.

The same process was subsequently rolled out to all specialists, with similar results. “PCPs are happy because we can get their patients to the specialists in a faster, more appropriate manner. At the same time, specialists now see only the patients they need to see. The McKesson solutions make it possible,” says McWilliams. “InterQual is critical to ensuring the system doesn’t get bogged down with inappropriate referrals, and enabling us to manage those populations with quality.”

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