Benefit of Implementing Electronic Referral in Ambulatory Area - Case Study Example

THE BENEFIT OF IMPLEMENTING ELECTRONIC REFERRAL IN AMBULATORY AREA Lecturer: Introduction Making reference to the UK healthcare system, Wilson et al. (2005) lamented that even though the number of ambulatory visits in various healthcare facilities have continued to increase over the years, there continues to be very little research and scrutiny of the ambulatory setting. This assertion is made in relation to high-risk inpatient areas including surgery, emergency department, and perinatal care (Manuel & Greenwald, 2007). Meanwhile as the number of patients visiting the ambulatory area continues to increase, it is appropriate and also makes sense that issues of health care quality and safety in this area of the healthcare setting will be taken very seriously. As argued by Hing, Burt, and Woodwell (2007), when the issues of health care quality and safety at the ambulatory area are taken very seriously, the number of referrals that are made to secondary treating practitioners will be decreased significantly. This is because most of the diseases and illnesses that are reported by patients will be adequately dealt with at the primary healthcare stage. But before such a time is reached when the number of referrals to secondary care is decreased to desirable levels, it is only appropriate that the right measures will be put in place in improving referral processes from the ambulatory area to other high risk areas of the hospital. Clinical situation The current evaluative exercise is based on a clinical situation within health facility of the writer, which acts as a case study for developing an evaluation strategy. The clinical situation is founded on the issue of employee resistance to change in the referral process, which nearly caused the precious life a patient. The actual clinical situation had to do with the breaking bad news of referral to emergency care to the patient. Upon a number of visits to the ambulatory area, the patient was diagnosed to have a serious life limiting illness. This meant that the referral to emergency care was necessary. According to Cullen, Hall and Golosinskiy (2009) when faced with a clinical situation that deal with breaking such bad news, it is important that the health practitioner will show much professionalism in the way the news is communicated to the patient. Groopman (2007) added that an important determinant of how patients receive bad news from health practitioners is the mode or approach by which the news is carried to the patients. This implies that the mode or approach to referral, which comes as a means of communicating the news to the patient could trigger emotions among the patient. Meanwhile, the hospital had instituted an electronic referral (eReferral) system to nurses at the outpatient department of the hospital. This was done with the overall understanding that eReferral will make the referral process easier and patient-centred (Burt, 2005; Tuttelmann, Luetjens & Nieschlag, 2006). Since the introduction of the eReferral system at ambulatory area however, nurses have resisted the change and therefore continue to use the traditional approach to referral in most cases. This is especially when these nurses are not under specific supervision. Based on this, the nurse in charge of the current clinical situation failed to adopt the use of the eReferral system in communicating the new of referral from the ambulatory area to the emergency care to the patient. Indeed due to the manual nature of the traditional referral process (DesRoches et al., 2008), the nurse had to use extensive verbal communication as part of the paper referral form that was given to the patient. The patient however found the information she was receiving from the nurse as too shocking and unbearable, leading to her passing out while the details of the referral was being explained to her. This case creates the need for there to be a critical evaluation of the eReferral system at the ambulatory area to understanding the real benefits that come with the new change. The rationale for this aim of the case study is that if nurses at the ambulatory area really have an adequate understanding of the benefits of eReferral, they would be in a better position to embrace it has been argued out by Thammasitboon and Cutrer (2013). But in order to be convinced about the benefits, it is important to have an evaluation strategy in place, an example of which this paper seeks to propose. Area of judgement in practice Ahead of proposing the evaluation strategy to use on the eReferral system, it is important that the area of judgement will clearly be identified in practice. As it background of it has been mentioned, the issue of eReferral in ambulatory area is the area of judgement in practice that is focused on in this case study. This is because there is currently a misplaced judgement between nurses and their supervisors on the use and benefits of the eReferral system in the ambulatory area. Whereas the supervisors and managers have often attempted to communicate the benefits of the system, nurses show apathy towards it usage. Writing on eReferral, Maekawa and Majima (2006) explained that this is an electronic platform used in the healthcare setting which makes it possible to transfer patient information from a primary treating practitioner such as the one at the ambulatory area to a secondary practitioner such as the one at the emergency unit or perioperative unit. This means that eReferral is generally an electronic management system of referral cases at the hospital. Emphasising on the functionality of this electronic platform, Evans, Nichol & Perlin (2006) indicated that eReferral comes as a replacement of the paper-based referral process given the fact that the former serves all the roles of the latter, even with some enhanced performance features. By the use of the eReferral system, Stille et al. (2006) was confident that the goal of seamless communication and information sharing between practitioners and patients will be achieved. Certainly, if there was such seamless communication and information sharing between the nurse and the patient in the clinical situation described, the resulting outcome would have been different. Searching through literature, there were a number of studies and researches that clearly support the use of eReferral in the ambulatory area due to the benefits it offer both practitioners and patients. In the judgement of Glintborg, Andersen & Dalhoff (2007), eReferral is very beneficial in increasing efficiency with the referral process. Such increase in efficiency is said to come about as practitioners are able to do more with very limited resources and also with very limited time frame. This is generally achieved because most forms of manual processing of data which could be associated with fatigue, stress and tiredness, all of which slow down the referral process are taken care of when using the eReferral system (Royal et al., 2006). Morris et al. (2006) was also confident that the handling of clinical data can be said to be secure whiles using an eReferral system. The security of data comes where the right technology based approaches and interventions are used in preventing the wrong people from gaining access to the data that is supposed to be given to the customer on a confidential basis. Again, chances of referral letters or forms getting lost in the mail or through any other mode of transfer are unlikely (Arora et al., 2005). This is because of the backup structure that comes with the use of the eReferral system. Proposed evaluation strategy appropriate for eReferral in ambulatory area This section of the paper is dedicated to proposing an evaluation strategy that will be appropriate for knowing the benefits of eReferral in the ambulatory area of the hospital in the case. It is important to mention that the proposed evaluation strategy is multidimensional as it is based on both theory and practice. Theoretical approach to the evaluation From a more theoretical approach, two major evaluation models are proposed to be used at ambulatory area in assessing the benefits of the eReferral system peculiar that that healthcare setting. These two models are cost-benefit analysis and SWOT analysis. Commonly used in economic and finance situations, Schauberger and Larson (2006) noted that cost-benefit analysis can be adopted and used in the healthcare sector to assess or evaluate the impact of new systems on the overall healthcare delivery process. This is because cost-benefit analysis is a theory that offers a technique for assessing the monetary social cost and benefits of a capital investment project over a given timeframe (Jha et al., 2006). In the current circumstance, the monetary social cost involved with the use of the eReferral can be said to be the amount of money that the hospital will be saved when there is seamless communication and information sharing between practitioners when medical errors are reduced as a result. Again, monetary social cost can be said to be involved for patients when a successful referral process ensures that any forms of complications with their health are eliminated. What is more, the eReferral system fits into the definition of capital investment project as it required the hospital huge sums of money in bringing the system into function at the hospital. With this background created, the cost-benefit analysis is expected to be undertaken through a desk research that quantifies the cost of using traditional referrals over the eReferral in knowing which of them produces better benefits. The second theoretical approach to the evaluation of the eReferral system can be done with the use of the SWOT analysis. The SWOT analysis is another theory founded approach to desk research where data or information is gathered from official and other authenticated sources about a project to know the strengths, weaknesses, opportunities and threats that come with the project (Modak et al., 2007; Ruotsalainen & Manning, 2007). In the current case, the project in question can be said to be the eReferral system which administration of the hospital has spent several amounts of money on to ensure that it becomes operational. As an evaluation strategy, the strength of the eReferral system will be identified by looking at ongoing achievements that can be attributed to the system. The weaknesses of the system will also be known by focusing on the limitations that the presence of eReferral has brought. What is more, the opportunities of the system can be identified by focusing on future projected outcomes that eReferral can bring. Then also, the threat will be found by highlighting on any possible impediments that can retard the successful implementation of the system. Once the outcomes of these four factors are known, a metric will be used in putting together the strength and opportunities on one side, and the weaknesses and threats on another side. After this, when the strengths and opportunities are found to outweigh the weaknesses and threats, then the system can be evaluated as beneficial and thus worth maintaining. If the opposite result is achieved, then a decision will be made to discontinue its use. Primary evaluation strategy As the theoretical approaches to evaluation offer more desk-based procedures to assessing the eReferral system, there are practical evaluation strategies that are expected to be implemented by use of primary evaluation. The primary research based evaluation strategy that is recommended for use is the stakeholder analysis strategy. Bell (2005) explained stakeholder analysis is be an evaluation strategy that requires the collection of opinion-based data from stakeholders for further scrutiny and decision making about the phenomenon on which the data was collected. In line with the case therefore, the stakeholders to be used in the data collection will be referred to as the sample size and will be made up of both internal and external people who are affected by the implementation and use of the eReferral system. The sample size will therefore be expected to comprise an average of 10 people who are selected from such stakeholder groups as patients, nurses, nursing supervisors, IT system managers, and healthcare regulators. The need to vary the background of the respondents in the sample size is to be done so that it will be possible to have very wide array of opinions that can be considered as neutral, balanced and fair. Certainly when the decision making process on the benefit of the eReferral system is to be based on the views and opinions of few stakeholders, it will be difficult to generalise the outcome of such an evaluation process (Kierkegaard, 2011). As part of the stakeholder analysis, it is expected that an interview guide will be prepared to be used in the course of collecting data from the respondents in the sample size. The interview guide will be necessary to ensure internal validity in the evaluation process. What this means is that the presence of the interview guide will ensure that the evaluation measures exactly what it is intended to measure. Certainly when there is no interview guide, chances are that the evaluator will deviate from collecting data to focus on the benefits of the eReferral system. But when the interview guide is prepared at forehand, it can be expected that only questions that are well curtailed towards measuring the real benefits of the eReferral system are included. Again, because the stakeholder analysis will comprise stakeholders with different backgrounds, it will be expected that there will be different interview guides to cater for each group of stakeholders. This does not mean that each of the 10 respondents will have a different interview guide. Rather, there are five stakeholder groups identified. These are patients, nurses, nursing supervisors, IT system managers, and healthcare regulators. There will therefore be five different interview guides all of which will be focused on measuring the real benefit of the eReferral system from the perspective of the stakeholders. In effect, if 2 people are selected from each of the groups, each of the two will be interviewed with the use of the same interview guide. When using stakeholder analysis as a form of evaluation strategy, the approach to undertaking the interview has been noted to be very important in affecting the outcome of evaluation (Ghauri & Gronhaung, 2010). More specifically, Stangor (2007) recommended a stakeholder analysis that is conducted as a focus group rather than a one-on-one interview. For example, whiles interviewing a nurse, a patient or a supervisor as part of the stakeholder analysis, it will be important to ensure that the opinions and answers that these people give are the collective opinions and answers of the whole stakeholder group in which they belong. For the proposed evaluation strategy, one of the ways to achieve this will be by ensuring that the interview guide is given to the respondents ahead of the interview. The respondents will then meet with other people in their stakeholder group, or have a consultation among the group. By so doing, the respondents selected to represent their stakeholder groups would have a fair knowledge of the position of the larger group in terms of the items being presented to them as part of the interview (Gill & Johnson, 2009). In effect, the respondents will only become delegates who will furnish the evaluator with information from the perspective of the larger stakeholder group. After the series of interviews, a discourse analysis is proposed to be used as the major form of data analysis procedure in determining the trend of responses as far as the benefit of the eReferral system is concerned. Again, where the analysis shows that the system is beneficial, it would have to be continued but where the analysis shows otherwise, its usage would have to be terminated. Reflection There has also been evidence given in literature by Haig, Sutton and Whittington (2006) to support the position that eReferral is beneficial in there is standardisation with set of information for each patient, there is reduction in medical errors, and there is general improved patient safety and quality of care when using the eReferral system. From a more personal and professional judgement as a nursing supervisor, there are evidences that can be given to evaluate the benefits of eReferral in the hospital under the case study. In the first place, personal experience has showed that eReferral is patient centred rather than physician centred. The reason for this judgement is that with the use of eReferral, the physician only becomes a facilitator of the referral process as the patient is the person who has all the information and data on healthcare delivery being focused upon. Secondly, the eReferral system is seen to be a system that improves the productivity of healthcare workers (Kuhn, 2014). This benefit can be seen with the reduced duration that practitioners at the ambulatory area spend on preparing referral forms. With the duration of time gained, the practitioner can be engaged in other productive activities. After reflecting on the major benefits with the eReferral based on what has been experienced at the workplace and learnt in literature, it can be stated with confidence that the use and adoption of the system in the ambulatory area will come with a lot of merits and thus worth considering. Conclusion The study identified a gap in research where there is limited number of study on ambulatory area of hospitals when compared to secondary care areas. The current situation can therefore be said to have created a problem for healthcare professionals operating in ambulatory areas when it comes to gaining adequate evidence based information for decision making of their work setting. Some available studies however confirm the usefulness of using eReferral at the ambulatory area. Even though there will continue to be numerous literature that openly support the usefulness of the eReferral system due to its benefit, Smith, Araya-Guerra & Bublitz (2005) warned about generalising medical outcomes for every other medical facility. What this means is that it is always important that each health facility will have its own means or methodology by which its medical systems including an eReferral will be evaluated for their benefits. It was on this basis that the evaluation strategy for the case was recommended. The reflection has helped to confirm that the proposed evaluation will result in a confirmation of the benefits of the eReferral system. This conclusion will however not be made without admitting that there are possible challenges that could impede the successful implementation of the system. In literature, Hertzum and Simonsen (2008) pointed to poor communication of change processes as a leading factor to employee resistance to change. Hillestad et al. (2005) also added that poor manager-employee relationship could cause resistance to change. From a personal perspective also, it can be said that the resistance to change in the identified case was due to apathy on the part of nurses as they were reluctant to change from an old system they were more familiar with to a new one. 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