1.0        Introduction

Referral / Consult Management is a complex, multi-factorial workflow whose implementation within the MHS has historically been suboptimal. Several large scale attempts to improve the process and rectify long-standing provider frustrations have failed.

Cognitive Medical Systems, Inc. (Cognitive) is a woman owned, service disabled veteran small business located in San Diego, CA, specializing in standards-based, advanced concept engineering solutions for clinical workflow, decision support, and data modeling projects. Our domain and field expertise in designing, implementing, and integrating medical Service Oriented Architectures for the Veterans Administration, Indian Health Service and Department of Defense enables us to develop optimized solutions to complex problems.

The following is a brief overview of five critical referral management challenges that must be addressed before a satisfactory solution can be achieved. Cognitive has the experience and technical ability to develop workflow centric, highly integrated solutions for one or more of these impediments. The brief descriptions below highlight our use of intelligent, rule-based workflow management that is our particular value proposition.

2.0        Provider Referral Assistance

A significant source of frustration for providers, patients, and the healthcare delivery system is the number of consults that are unnecessary, premature, or referred to the wrong specialty or department.  Numerous factors contribute to this situation, not the least of which is the lack of guidance provided to the referring physician at the time the consult is ordered. Referral guidelines like those of Milliman & Robertson have historically been found useful, but the MHS has not integrated such guidance into the AHLTA workflow. It continues to rely on local, labor-intensive educational efforts to disseminate preferred referral criteria in part because general care guidelines do not adequately reflect local subspecialty preferences and management styles, but also because neither CHCS nor ALHTA provide any assistance for ensuring patients with get referred to the correct clinic or to a preferred subspecialist within the clinic.

Cognitive proposes to develop a workflow sensitive, consult /referral guide for providers that can deliver general, standardized consult criteria for any MHS clinic, and can be customized with idiosyncratic clinic preferences as appropriate. Using automated rule based checks validating that prerequisite treatments, x-rays, or laboratory tests had been ordered, the Consult Tool could easily monitor the referral process for compliance with recommended or required practice. 

Consult Decision Support could be supplemented with a direct referral approach we call Virtual Clinics, a technique by which regular CHCS appointments for individual providers can be tagged and displayed to other AHLTA users as disease specific “clinics”.  For example, the system would allow Cardiology to create an “Adults with Congenital Heart Disease & Arrhythmias” clinic thereby allowing patients to be referred directly to the right provider and thus avoid the delays that occur when a subspecialty clinics insists on 100% review for booking the consult.

3.0        MTF Referral Review & Routing; Right of First Refusal Management

Many MTFs use a Referral Management Center to alleviate the bottlenecks that can occur at the subspecialty clinic and off loading the consult review process to a dedicated, centralized staff more familiar with eligibility verification, benefits, etc. The Virtual Clinic System is arguably even more useful to the RMC that is now tasked with validating and routing internal consults to the correct clinic and/or staff member.

The RMC is also the starting point for the “Right-of-First-Refusal” (ROFR) process that occurs when a network provider initiates a referral that the MTF has 24 hours to review and adjudicate.  As most network referrals are delivered via fax to the RMC, the typical review is a paper-based, manual process performed using guard mail. Some RMC have attempted to transfer the information in the fax to an electronic CHCS consult order as a way of routing the consult through the medical center, but this is horrible waste of effort. Not only are almost 50% of such referrals refused (wasting the effort required to enter them), it is also not uncommon for any accompanying data/clinical documentation to be omitted when the request is transferred from fax to electronic order.

Cognitive’s expertise with standard-based interfaces, messaging, and automated workflow, suggests several ways to streamline almost all phases of this process, from referral receipt to routing and review.  We could design and prototype a flexible and configurable workflow system that would largely automate the process of generating CHCS consult orders, facilitate the routing of supporting documentation, and otherwise monitor the ROFR process to ensure a decision on whether to accept the referral is made in the required time frame. The RMC ROFR System could also facilitate the appointing of any accepted consult, the initial notification of the patient, and then any additional appointment reminders that might be sent to the patient’s home phone, cell, email or SMS text account. Cognitive has extensive experience with the CHCS appointing and consult management system, architected the original prototype of the Tricare Online appointment booking system, and probably has more CHCS write-back expertise than any MHS vendor other than SAIC. The proposed system would satisfy metadata, administrative and workload requirements automatically and virtually eliminate manual data entry.

4.0        Referral to MCSC and Delivery of Supporting Documentation

A major challenge facing the RMC when an MTF referral is sent to the MCSC, and a source of complaints from our network providers, is the task of providing a complete referral package including supporting documentation, labs, study reports, etc.  Under the current workflow, this information is either severely truncated, results in reams of fax paper, or involves a labor-intensive scanning process to generate a more manageable pdf.

Cognitive has extensive experience in healthcare interoperability and standards, particularly with HL7 semantics and the emerging Nationwide Health Information Network (NwHIN). Our engineers contributed significantly to the development of this reference implementation for FHA and its production deployment for the Department of Defense as part of the Virtual Lifetime Electronic Record demonstrations in San Diego early last year. This experience suggests several ways in which existing MHS capabilities can be refactored and applied for internal point-to-point clinical documentation exchange between entities within the Tricare health plan for the purposes of treatment. Automatically creating a Summary of Care record and transferring it with every referral to our network would not require patient consent or the elaborate fine-grain access control system we prototyped for MHS VLER exchanges.

5.0        Consult Tracking

Under the new T3 contracts, the MCSC is not required to ensure that consultants return results to the MHS or the original referring provider. That responsibility is now shouldered by the RMC or its equivalent at the MTF.  Unfortunately, our direct care system is neither staffed nor equipped to manage this consult result-tracking requirement. The principle reason for this inability is the lack of visibility into how many network referrals are a) actually booked and b) eventually seen. In reality, 40% of our patients never follow through with their authorizations.  The remaining 60% may get their referrals, but the MTF / referring provider is not notified by either the MCSC, who is responsible only for paying the claim, or by the consultant, who is often are at loss as to how to contact the referring provider even if they wanted to

Cognitive envisions a Consult Tracking application for the RMC that helps them determine a) who received an authorization for a referral, but failed to booked an appointment or to follow through, and b) for those that are seen, when their evaluation is complete and a consult result might rightfully be expected.  There are several “paths” that a patient can take before they are eventually seen by a network provider, but unfortunately none collect good metadata that would allow a precise and efficient tracking metric to be built directly. The proposed Consult Tracking System will, therefore, facilitate the real-time notification of when a claim is paid for an authorized referral.  This will allow us to develop other tools to give network providers consistent and reliable means of transmitting results back to the RMC and to identify the referring provider, to automatically track what consult results are expected but missing, and to send reminders when the consultant fails to provide the consult report as expected.

6.0        Consult Storage in AHLTA

A final and particularly frustrating obstacle, is the difficulty in ensuring that consult results that are returned, get included in the patient’s AHLTA record.  This is largely a result of inconsistent and poorly publicized mechanisms for network consultants to return the results in the first place. It is also a consequence of the labor-intensive process required to accept the faxed results (the most common delivery mechanism) and of ensuring that all the metadata required to store the result in AHLTA are available.

Cognitive’s past experience with MHS systems and prototypes again suggests a cost effective solution that addresses both metadata management concerns and the actual storage of consult results into AHLTA. Cognitive’s CTO was the principle architect for the NMCSD document integration prototype that was later productized and DICAP certified as the AHLTA Document Engine. This AHLTA add-on enabled largely automated receipt and storage of dictations, binary images, scans, etc. in the appropriate locations within CDR. It even provided Windows drivers for AHLTA work stations to “print” their non-structured documents, letters, emails, directly into AHLTA.  The user interface for the review, editing, and ultimate submission of these documents were all web-based applications seamlessly integrated into the existing AHLTA thick client.

Cognitive suggests this prior MHS investment, shelved because of contracting irregularities in the DFEI project, could be resurrected and refactored for the purposes of ensuring consult results are retrieved, reviewed, and stored into AHLTA in a timely and workflow appropriate way.

7.0        Conclusion

The above concepts and prototypes leverage Cognitive’s unique emphasis on rule-automated, workflow-centric solutions to basic MHS challenges. We specialize in standards-based, advanced concept software engineering solutions for organizations where real world experiences with healthcare standards, clinical workflow, decision support, and/or legacy system integration are needed for success.  Our core value proposition is our ability to deliver a small, highly integrated team with the business analysis skills essential for project success.

It is worth emphasizing that the GUIs for the ideas above (e.g. Consult Criteria And Referral Guide) would be web-based and embedded seamlessly into AHLTA using the techniques our CTO pioneered for the MHS while at the Naval Medical Center San Diego. This technique is now used in numerous MHS projects including NHIN, VLER, etc. and provides an easy migration path to the eventual EHR-Way-Ahead client that is also anticipated to web-based.