Where, oh where, are the referral rules?

8 minute read

Referrals are back in the wider healthcare conversation. This time, it’s about tech.

eReferrals promised to remove the back-and-forth hassle of getting a patient into hospital emergency. Instead, it’s made it more difficult for GPs referring out of area.

Benjamin Franklin may as well take note, because there are in fact three certainties in this world: death, taxes and GPs getting fed up with public hospital outpatient referrals.

Named referrals have long been a thorn in the GP’s side.

Just this week, the RACGP used the mid-term review of the National Healthcare Reform Agreement to lobby the government to adopt stronger language and regulations to prevent hospital outpatient departments from controlling referral pathways by requiring named referrals.

Requiring a referral to be named to a particular doctor as a precondition of it being accepted is already against the law, but – as many GPs can attest – this does little to stop hospitals from requesting named referrals anyway.

A relatively new and emerging issue, though, is electronic referrals.

Most jurisdictions around the country are either planning to roll out or in the process of rolling out some form of eReferral system, with the end goal of putting fax machine manufacturers permanently out of business.

eReferrals tend to use hospital-generated templates which, in a perfect world, are easy to download and integrate seamlessly with practice software to pull in patient identifiers, test results and medication lists.

These are then sent directly to the hospital, and in some cases GPs can even track the referral as it makes its way through the system.

The RACGP lists just a few of its issues with eReferrals in its submission to the National Healthcare Reform Agreement.

“Many hospitals will have unique templates GPs are required to use to refer patients but provide little guidance on how to fill them out and update them without notifying referring GPs,” the college says.

“These templates rarely integrate with practice management software, requiring GPs to fill them out manually, taking time away from seeing patients.

“These templates can turn referrals into a bureaucratic mess, requiring GPs to spend valuable time sorting through PDFs, and going back and forth with hospitals about which template is the correct version.”

The “bureaucratic mess” observation rings particularly true for Sydney GP Dr Brad McKay, who recently tried to refer a patient who had moved to Cairns for ongoing care of an existing problem.

His initial referral, which he says had all the relevant information including patient details, the date and his signature, was rejected.

Cairns Base Hospital requested that he resend the referral using its specific form.

The form is accessible on the Far North Queensland HealthPathways site, which requires a login. A new login can only be created by the local HealthPathways site administrator.

When Dr McKay was eventually granted access to the site and downloaded the correct template, he estimated it took an additional half hour to fill out all fields on the form.

“All up it was like a day for them to get back to me with the password and code for HealthPathways, which I didn’t really want because I don’t work in Cairns,” he tells The Medical Republic.

HealthPathways itself is an online manual administered by Public Health Networks, and contains information about who GPs can refer to, what clinics are available and – evidently – referral templates.

A secondary technology is then used to whisk the referral from the GP’s desk to the hospital.

Because Medicare only remunerates Dr McKay for his work while directly in front of a patient, there was no reward for the additional effort required to get the referral in.

“We should be able to write a referral, and either email it directly to the clinic or fax it if we’re really wanting to be old fashioned about it,” Dr McKay says.

“We shouldn’t have to have a password and a user code and then get on to HealthPathways and then have to download a template to get access to the patient’s care, because that just creates hurdles and puts blocks in the way for patients to receive treatment.”

Cairns Hospital and Health Service has since updated its website to make the referral pathway clearer, but tells TMR that it will be keeping the referral document behind a login.

“Registration to access this website is necessary, as it contains specific clinical management information, as well as private contact information for local specialists,” a spokesman says.

With the rise in telehealth meaning that doctors and patients will not always necessarily be in the same state, Dr McKay is concerned that drawn-out processes involving logins and templates will become the norm.

Perhaps these troubles should have been expected – even on a local level, jurisdictional issues plague GPs.

Adelaide GP Dr Alvin Chua’s practice sits at the boundary of two hospital districts and he says that there’s just one hospital in the area with an eReferral set up.

“Are we geography experts or something? Sometimes we actually have to open Google Maps and say ‘where do you live?’” he tells TMR.

“And you sit there and go, ‘oh yeah, this imaginary line here is [one LHD], this imaginary line here is the other [LHD]’ to work out which hospital to refer them to.”

eReferrals will presumably offer an automated solution to this issue at some point, in that the software should, in theory, alert GPs if they are sending to the wrong hospital service or at the very least make it easier to redirect the referral to the appropriate district.

But because the implementation is so haphazard, there will be an undetermined amount of time where Dr Chua is sending some referrals via fax and some via eReferral.

This exact scenario already faces RACGP practice technology and management expert committee chair Dr Rob Hosking.

“I work in Bacchus Marsh in Victoria, which is halfway between Melbourne and Ballarat and also near Geelong,” he says.

“We could send our patients to … any number of hospitals in Melbourne, and each one of those hospitals has its own referral template for many conditions – we don’t know until our referral gets rejected.

“And then they say, ‘oh yes, you’ve got to do [use HealthPathways] or ‘no, you can’t fax it, you have to use our special messaging system’, which is not necessarily [a common one like] HealthLink or Argus.

“But far and away, these hospitals are still insisting on faxing.”

Time-wasting public health referral runaround headaches are unlikely to improve any time soon.

For a start, there’s no one national standard for what needs to be in a referral, leaving it open for local health districts, and sometimes individual hospitals, to create their own standards.

The only requirements under national law are that the referral is in written format, addressed to a hospital department or specialist and that it includes the referring practitioner’s signature and the date it was written.

According to a Department of Health Spokesman, the reason it’s so vague is that the National Health Reform Agreement recognises that state and territory governments are responsible for the systems and day-to-day administration of public hospitals.

“Decisions regarding the detailed criteria and processes for accepting a referral for a patient to a specialist outpatient department at a public hospital are a matter for individual state and territory governments,” the spokesman tells TMR.

The only rule for the hospital is that it cannot control a referral pathway so as to deny access to free public hospital services by requiring that the referral be named to a specific doctor.

To be clear, a hospital is within its rights to request a named referral – which then allows it to charge Medicare for that patient’s care – but it is not allowed to make the named referral a prerequisite for care.

The DoHAC allegedly polices this “through the provision of guidance, online education resources and targeted letters and other compliance activities including tip-off monitoring”.

Because the government has left systems administration entirely up to state and territory health departments, it’s not necessarily surprising that there’s no standardised approach to eReferral projects.

Best Practice Software, one of the two leading GP practice management systems, says the haphazard state-based approach meant that an innovation which was primarily meant to make the sharing of health information more seamless has in fact left it siloed.

“Best Practice Software supports both a transparent and consistent approach to eReferrals, rather that bespoke and proprietary integrations that aren’t applicable across the wider health landscape,” it tells TMR.

“BP is currently working with other practice management software vendors on developing a set of consistent standards, to enable a common approach to eReferrals.

“It is our hope that these standards will be utilised by clinicians, irrespective of the care pathway they are providing.”

While the prospect of having one national standard is exciting, it’s worth mentioning that we’ve been close to making the One True Referral before.

The National Electronic Health Transition Authority (NEHTA), predecessor to the Australian Digital Health Agency, worked with stakeholder groups to create a universal referral template around 10 years ago.

“It’s been ignored,” Dr Hosking says.

“Everybody just goes on and does what they want to do in each jurisdiction or each sub-jurisdiction.

“Unfortunately, the lonely GP is a very soft voice.”

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