Electronic referral systems in health care: a scoping review

Figures & data

Table 1 MESH terms and keywords

Search	Key term		Term 2		Complementary term
#1	Electronic referral	AND	-	OR	Referral
#2	Electronic referral		Cost		Referral/cost analysis
#3	Cost-benefit analysis		Electronic referral		Cost-effectiveness/referral
#4	e-referral		-		-

Figure 1 Selection flow for published literature*.

Table 2 Study characteristics

First author	Country	Objective	Study design	Sample characteristics	Referrals from–to	Type of outcomes
						Cost or economic evaluation	Changes in quantity of referrals	Changes in quality of referrals	Changes in workflow efficiency or productivity
Cannaby^Citation9 (2004)	Denmark	To evaluate the cost-benefit of electronic referral system	Time-motion	41,235 referrals	General Practitioner to Hospital	YES	-	-	-
Yeuen Kim^Citation10 (2009)	US	To assess the impact of electronic referrals on workflow and clinical care.	Web-based questionnaire	298 General Practitioners	General Practitioner to Hospital	-	-	-	YES
Scheibe^Citation11 (2015)	US	To evaluate the use and impact of an electronic referral system in rheumatology		2,105 referrals	General Practitioner to Hospital	-	-	-	YES
Scott^Citation12 (2009)	UK	To evaluate time to process a referral	Interviews	99 referrals	General Practitioner to Hospital	-	-	-	YES
Kim-Hwang^Citation13 (2010)	US	To determine the impact of electronic referral on specialty referrals	Visit-based questionnaire	505 questionnaires	General Practitioner to Hospital	-	-	YES	-
Corwin^Citation14 (2014)	New Zealand	To assess whether feedback improves the quality of referral letters from general practice to secondary care and how electronic referrals affect the quality of referral letters.	Referral letters’ Feedback from peers	340 referral letters	General Practitioner to Hospital	-	-	YES	-
Chambers^Citation15 (2015)	US	To facilitate and sustain patient referral using an Electronic Health Record and a provider education program	Pre-post intervention analysis	75 referrals	General Practitioner to Diabetes program	-	YES	-	-
MacGregor^Citation16 (2009	Canada	To evaluate the completeness and adequate number of referrals using an electronic referral system	Pre-post intervention analysis	10 clinics (referrals number was not reported)	General Practitioner to Pediatric Hospital	-	YES	-	-
Doumouras^Citation17 (2018)	Canada	To determine the impact on referral rates to bariatric surgery after converting to an online referral system from a fax-based system.	Pre-post intervention analysis	5,317 referrals	All type of physicians or specialists to the Ontario Bariatric Network	-	YES	-	-

Table 3 Summary of main study findings and conclusions

Author	Main findings	Authors’ conclusion
Cannaby^Citation9 (2004)	Total health system annual savings of €3,512,146 associated with the implementation of the e-referral system. Annual potential savings in direct costs of €1,900,000. Compared with the paper-based referral process, the e-referral system saves up to € 1.6 in the average cost per minute spent during the referral process. Savings of €0.65 per capita if all the referrals are sent electronically.	The study suggests that significant cost savings are possible from the widespread adoption of electronic messaging in healthcare. Further research is needed to understand what the quantifiable benefits of electronic communication in healthcare are.
Yeuen Kim^Citation10 (2009)	72% of Primary Care Providers felt that electronic referrals have improved guidance of the pre-subspecialty visit workup 89% of participants respond the e-referral had improved the process overall. 54% of participants felt an improvement in wait times for new appointments. 79% of participants reported a positive change in the workflow and clinical care 7% were dissatisfied using the e-referral system	The majority of PCPs felt electronic referrals improved quality, access and clinical care. The impact of e-referral system ingenerate timely access to care should be considered for further analysis.
Scheibe^Citation11 (2015)	Pre-consultation exchange increased from 55% in 2008 to 74% in 2011 due to the use of e-referral system From the total pre-consultations, 63% were subsequently scheduled for a face-to-face appointment.	The e-referrals system allowed specialists to conduct a pre-consultation exchange to determine the need of a consultation. The e-referral system allowed for triage a high number of referrals.
Scott^Citation12 (2009)	81% of e-referrals were processed within one hour after received. The e-referral system improved satisfaction. From a 10-point Likert scale, the minimum score was 8.	Findings reported improvements in the speed with which referrals were sent to the central office as well as the speed with which they were processed once received
Kim-Hwang^Citation13 (2010)	The reason for referral was difficult to identify in 19.8% of medical visits using a paper-based referral compared to 11% in the eReferrals (p=0.03). 2.6% of the eReferrals were deemed not completely appropriate compared with 6.4% of the paper-based referral (p=0.21). Medical specialty clinicians indicated that they requested follow-up in 84% of paper-based referrals vs. 90% of e-referrals (p=0.06). Surgical specialists indicated that they requested follow-up in 76.2% (paper-based) vs. 58.1% (e-referral).	The e-referral system helped specialists to identify the clinical question for referral. Inappropriate referrals were lower using the e-referral system compared with the paper-based process The adoption of the e-referral system was associated with the reduction of unnecessary follow-up for patients.
Corwin^Citation14 (2014)	The implementation of an e-referral system did not lead to improvements in the quality of referrals compared with the paper-based process (p=0.20) Feedback from peers (GP’s) improved the quality of referrals from 81.4% to 86.9% of adequate referrals (p-value 0.05)	Feedback from peers to GP seems to have a better effect in the quality of referrals than the adoption of an electronic referral system.
Chambers^Citation15 (2015)	On average per month, patients referred increased from 1 to 3 after the e-referral system implementation Referrals increased from 3 to 6 on average per month after the e-referral system implementation combined with the provider education program.	The segmented regression analysis showed that the increase in the number of referrals was significant when the e-referral system and the provider education program were combined and not significant when the e-referral system was evaluated alone.
MacGregor^Citation16 (2009	Before the implementation of the electronic referral system, 30% of referrals were either incomplete or inappropriate (before the implementation of the e-referral system). After the implementation of the electronic referral system, incomplete referrals increased in 2.7% and online referrals increased 6%.	The e-referral system seems to have benefits regarding the incompleteness of referrals. Authors mentioned that other benefits can be: increase workflow efficiency, ensure patient´s information confidentiality among others.
Doumouras^Citation17 (2018)	Referrals increased (overall) by 68% after the e-referral system implementation. GP that are female, live within 50k of the Health Center and with less than 5 years of experience, has a greater odds to refer using the electronic referral system	Compared with the paper-based referral process, the implementation of an e-referral system increases the number of referrals (significant).

Cannaby S, Wanscher C, Pedersen C, et al. The cost benefit of electronic patient referrals in Denmark full report. MedCom Available from: https://www.medcom.dk/media/1173/the-cost-benefit-of-electronic-patient-referrals-in-denmark-full-report.pdf. Accessed 115, 2017.

 Google Scholar

Yeuen K, Chen A, Keith E, et al. Not perfect, but better: primary care providers’ experiences with electronic referrals in a safety net health system. J Gen Intern Med. 2009;24(5):614–619. doi:10.1007/s11606-009-1087-519308334

 PubMedGoogle Scholar

Scheibe M, Imboden J, Schmajuk G. Efficiency gains for rheumatology consultation using a novel electronic referral system in a safety net health setting. Arthritis Care Res (Hoboken). 2015;67(8):1158–1163. doi:10.1002/acr.2255925623810

 PubMedGoogle Scholar

Scott E. The Swansea electronic referrals project. J Telemed Telecare. 2009;15:156–158. doi:10.1258/jtt.2009.00301419364903

 PubMedGoogle Scholar

Kim-Hwang J, Chen A, Bell S, et al. Evaluating electronic referrals for specialty care at a public hospital. J Gen Intern Med. 2010;25(10):1123–1128. doi:10.1007/s11606-010-1402-120512531

 PubMedGoogle Scholar

Corwin P, Bolter T. The effects of audit and feedback and electronic referrals on the quality of primary care referral letters. J Prim Health Care. 2014;6(4):324–327. doi:10.1071/HC1432425485329

 PubMedGoogle Scholar

Chambers E, Wylie-Rosset BA. Increasing referrals to a YMCA-based diabetes prevention program: effects of electronic referral system modification and provider education in federally qualified health centers. Prev Chronic Dis. 2015;12:150–294. doi:10.5888/pcd12.150294

 Web of Science ®Google Scholar

MacGregor D, Parker S, MacMillan S. Innovation in managing the referral process at a Canadian pediatric hospital. Healthc Q. 2009;12(3):73–79.

 Google Scholar

Doumouras, AG, Anvari S, Breau R, Anvari M, Hong D, Gmora S The effect of an online referral system on referrals to bariatric surgery. Surg Endosc. 2017;31:5127–5134. doi:10.1007/s00464-016-5054-z28447254

 PubMedGoogle Scholar