Summary
Aligned with the priorities of NHS England Outpatient Transformation in Dermatology, the newly-created team designed and implemented a local e-referral system (eRS), for referrals and advice and guidance (A&G), called Intelligent Triage. It is fully integrated into University Hospital Southampton’s electronic patient record and document management systems. Many UK hospital dermatology departments have increased their A&G/referral activity via the existing eRS for A&G or new commercial systems, but these may not be integrated into hospital electronic systems. This can result in costs and omissions in patients' records, performance data and workload management. The new A&G/referral eRS has overcome these limitations.
Method
The new ‘Intelligent Triage’ team was developed after initial scoping meetings to identify necessary team members across primary and secondary care, followed by regular Microsoft Teams meetings throughout the 12-month planning phase and the first six months of implementation (to date). Each team member worked on their aspect of the project between meetings and then reported back to the group. Examples included informatics developments, at the hospital end, and education packages for GPs regarding photographs, at the primary care end. The innovative team, many members of which had not worked together before, comprised CCG managers, primary care and intermediate dermatology leads, plus multiple hospital teams: dermatologists, outpatient booking, operational management, outpatient transformation and informatics. Final agreements were reached with local GP leads before implementation. Together the team created something new: an eRS for A&G/referral that is fully integrated into the hospital patient electronic record and hospital document management systems.
Results
The innovative outcome of this teamwork is the design and implementation of an eRS for dermatology referrals and A&G that is fully integrated into the hospital electronic patient record and document management systems. It is also straightforward for GPs to use and is part of a consistent hospital trust-wide approach, so GPs avoid having different referral pathways for different hospital services. Existing technology and existing expertise within the hospital workforce have been used. In addition, innovation has been made in primary care, with an education package, including video, that was specifically created for GPs about taking and uploading photographs and dermatoscopic photographs. The risks inherent in the previous eRS system for A&G have been overcome, as there had been no record of A&G within the patient's hospital electronic record. In the new, integrated system, dermatology A&G is now part of the patient’s hospital electronic record across all specialties. Data from the first three months of use (October, November and December 2021) show a total of 910 referrals. Of these, A&G was provided instead of an outpatient appointment (OPA) in 9.3% of cases. This is a smaller proportion than some dermatology departments because of strong local intermediate dermatology services; patients referred to hospital tend to have more complex conditions. GPs received A&G within 10 days. Waiting times for routine OPA reduced by 152 days in month one, 118 days in month two and 107 days in month three. While waiting for routine OPA, 8% of cases received advice to commence treatment during the wait period. This is a particular strength of a fully integrated system; when the patient attends clinic there is a record of the management that has already commenced. Bookings were made with the appropriate subspecialist OPA. People with skin conditions received the appropriate advice or appointment first time. Dermatology registrars received suitable training.
Sustainability and Spread
Sustainability is inherent in the new system, being based on existing eRS, hospital electronic systems and staff. The project was disseminated to relevant stakeholders at every stage of development. For example, the hospital dermatologists were trained to do electronic grading and distribution of GP educational resources for taking and uploading photographs in primary care. Ongoing outcomes continue to be disseminated via a regular stakeholders’ forum. In between, data, such as waiting times for outpatient appointments, are also shared in dermatology operational meetings. Training is a key element of the system. On one afternoon per week the dermatology trainees have a group session of referral/A&G supervised by consultant dermatologists. This is important for dermatology training for the future.
