A private, not-for-profit, 626-bed academic medical center, Boston Medical Center serves as the primary teaching affiliate for Boston University School of Medicine. The largest safety net hospital and 24-hour Level I trauma center in New England, BMC handles close to 30,000 inpatient discharges annually.
BMC partnered with Boston University School of Medicine and 15 community health centers (CHCs) to build Boston Health Net. BHN has fostered data exchange among CHCs using technologies from several vendors and others. We also created a Community Information Exchange (CIE) where interoperability, service and usability could flourish. By maximizing our legacy systems to create new solutions, we hoped to realize our vision of agility, innovation and “one patient, one record,” and focus on core strategies to enhance patient care, safety and quality, improve clinicians' experience and productivity, and quickly deliver solutions and functionality.
Having successfully deployed EMR on our main campus and at 10 CHC partners, we used a federal grant to build an HITSP-compliant CIE to provide interoperability between EMRs and enable collaboration among our partners.
We also wanted to replace our cumbersome, confusing and inefficient manual referral process. Among its limitations: lackluster tracking of referrals and outcomes, limited standardization, extensive paper-based rework by staff, inadequate information for specialists and lack of specialty feedback to referring providers. For patients, the referral process was long and cumbersome.
Having won a 12-month federal grant for innovative technology development and implementation from the Health Resources and Services Administration's High Impact HIT Innovations Grant Program, BMC assessed multiple vendors based on HIE experience, vision, innovation, focus and track record, and selected one based on its alignment with BMC's core strategies, its passion for innovation and its agility.
A key component of the CIE was the development of a referring physician dashboard to address the inefficient specialty referral process. That process often left specialists with inadequate patient information, referring providers with little or no feedback, referral coordinators with a very complex process, and all parties with insufficient referral tracking and issue mitigation. With the vendor, we implemented eReferral on BMC's CIE framework in eight months. eReferral includes:
- Referral lists, tracking and reporting
- EMR integration
- Provider dictionaries
- Insurance, instruction and clinical data
- Accelerated scheduling
- Patient-friendly summaries
By implementing eReferral, we were able to offer our 1,500 clinicians composite views of relevant patient information housed in varied systems and applications across the community. Clinicians and referral coordinators can find specialists, book appointments online, transmit clinical data and track referrals from beginning to end. Among the key results:
- Facilitation of clinical information exchange through tracking of referrals from initiation through completion
- Streamlined referral coordinator and clinician workflows
- Improved alignment with community health centers
- Centralized referral coordination
- Enhanced communication between PCPs and specialists
Without eReferral's ability to interoperate with multiple information systems, we would not have been able to implement or see tangible results in such a short period of time.
BMC's Community Information Exchange (CIE) has delivered tangible business value as demonstrated by increased hospital and clinic patient volume. Within a few months (June-November 2009), eReferral has generated these results:
- Information availability: BMC specialists now have the information they need to work up patients, while referring physicians have the information to continue care delivery.
- Patient care: Patients benefit from improved patient tracking and care coordination.
- Scheduled referrals: The proportion of scheduled referrals jumped from 30% before eReferral to 60% with eReferral.
- Referral coordination: The referral process is more standardized, complete, trackable and efficient.
- Time to referral appointments: The time-to-referral appointments decreased from a maximum of 69 days, pre eReferral (June 2009), to 3.5-7.8 days, post eReferral (Nov. 2009).
- No-show rates: No show rates declined from 25%, pre eReferral, to 23% post eReferral.
eReferral has generated an impressive projected ROI for BMC. Using grant funding of $543,535 and in kind personnel worth $90,905, BMC made an eReferral investment totaling $769,520. However, financial benefits totaled $7,384,482 for a 553.09% ROI. The total includes $6,476,022 generated through increased referral follow-through and $908,460 in reduced operating costs, as well as non-ROI
benefits such as expedited operations, faster scheduling, enhanced quality and safety and improved participant satisfaction.
Following are just some of the lessons learned from the BMC implementation of eReferral:
- Invest in clinical automation, balancing the benefits of safer, more efficient care delivery with IT's priorities regarding privacy, security, performance and availability.
- Shift to process-centric thinking, reducing reliance on functional silos to improve quality and operational performance.
- Focus on business intelligence, leveraging currently available data toward performance improvement and strategic decision-making.
- Integrate wireless devices and applications into clinical workflows.
Strengthen physician productivity and retention through remote access, but offer stronger authentication to satisfy compliance requirements.
By uniting BMC with outlying community health centers, small physician practices, patients, families and other health information exchanges, the CIE will eventually enable functions such as event alerts, population management and analytics, decision support, surveillance, registries, care management, information reconciliation, information reconciliation and care networking and communication.
Joel Vengco is chief applications architect and director at Boston Medical Center.
