Background/Purpose:  Rheumatology care is a scarce resource in some settings.  Health information technology holds promise in increasing the quality and efficiency of rheumatology referrals, but little information about its use for these purposes is available. The aim of this study was to determine the proportion of electronic referrals that are appropriate for pre-consultation exchange as well as to assess potential efficiency gains in a safety net health system.

Methods: The Electronic Referral System (eReferral) allows two-way electronic communication between referring and specialty providers for new patient referrals. Once a referral is initiated, several possible outcomes may result: either the patient is scheduled in rheumatology clinic, the consult is deemed not appropriate for rheumatology, more information is requested from the referrer to gauge the appropriateness of the consultation, or the question is answered entirely within the eReferral system without scheduling a clinic visit. The latter 3 constitute “pre-consultation exchange.”  We performed a retrospective study of a random sample of eReferrals for ambulatory rheumatology consultation between 2007-2012.  A sample of approximately 10% of eReferrals (n=257) was reviewed. The primary clinical question and disposition for these referrals was recorded. Using a blinded adjudicated, structured review performed independently by two rheumatologists, we rated each eReferral for pre-consultation exchange using the categorization above. 

Results: Between 2007-2012, 2383 eReferrals were sent to rheumatology.  Of the 257 referrals examined in more detail, the top reasons for consultation are shown (Table). 156 (61%) eReferrals were rated as appropriate for pre-consultation exchange.  The primary reasons pre-consultation exchange was recommended were: additional testing was needed to clarify or expedite the consultation request (37%), the clinical question was unclear (14%), or the consult was deemed not appropriate for rheumatology consultation (10%). Referrals for pain were most likely to be rated as appropriate for pre-consultative exchange and those for crystal arthropathies were the least likely (Table). Following the exchange, 49 (32%) eReferrals were able to be resolved without a clinic visit.

Conclusion:   We evaluated eReferral, an innovative program designed to improve the quality and efficiency of specialty referrals. Over half of the referrals to rheumatology were rated as appropriate for pre-consultative exchange. In addition, one-third of the referrals were able to be resolved without a clinic visit, suggesting that using an iterative referral system that facilitates communication between referrers and specialists has the potential to improve the triage and efficiency of new patient visits in a busy rheumatology practice, particularly in settings where rheumatologists are a scarce resource.