The ICT referral-application supports GPs in all steps of the referral process. In operation in 25% of Dutch hospitals it results in 60% less unnecessary hospital visits as well as unplanned referrals and a 45% reduction of second consultation visits to specialists.
Objectives and purpose
1. Lack of continuity of care: Historically cooperation between GPs and specialists is greatly undefined; common standardized agreements concerning referral indications are not present. 2. Lack of influence: GPs and their patients have little influence on the care-‘products’ and the access to hospital care. 3. Lack of transparency: GPs have insight neither in the different care-‘products’, nor in the quality hospitals supply. This leads to highly subjective referral decisions not based on best care for the patient.
Detailed description
A good referral can save money, build a bridge in care for the patient, increase patient satisfaction and can be monitored. There are big differences in quality of referral between GPs. The problem is 1. Lack of influence: GPs only have little influence on the care-‘products’ and the access of hospitals. 2. Lack of transparency: GPs have little insight in the different care-‘products’ hospitals supply, nor the quality and service of this specialist care. In the Netherlands an electronic system named ZorgDomein was developed to:a) optimize GP-medical specialist agreements, b) improve communication being mutual information transfer on and c) improve the role of GP as gatekeeper by giving GPs insight and influence on the care that hospitals in their referral-area supply. ZorgDomein is comprised of several elements: referral protocols (based on existing national guidelines as well as local working routines) that have been standardized in medical specialist-GP consensus meetings; up-to-date and/or guaranteed access times for specialist consultations; and patient information. Furthermore, it adds a new referral types to the pre- existing ‘normal’, ‘urgent’ and ‘semi-urgent’ referral: the ‘combined referral’ in which patients are referred for diagnostic tests and specialist consultation at the same time. Referrals can moreover be made without the need for GP-specialist telephonic consultation. Apart from but parallel to the introduction of ZorgDomein, the trajectory of patients within the hospital (ambulatory wards) is reorganized through the introduction of standardized care trajectories. It is from this combination of transmural and intramural, technical and organizational change, that the optimization of patient flow and the quality of care offered is expected. Effects were measured in several regions. Main results are a reduction of the unnecessary hospital visits (up to 60%), a reduction of unnecessary urgent-referrals (up to 59%) and a reduction of second and third consultation visits to specialists (up to 45%) due to logistic redesign of the workflow of the ward (introduction of one-stop shops). For the general practitioner the advantages are the insight in access times and compare care products of hospitals, rapid feedback (to GP) after referral and reduction of unnecessary telephone calls. For the medical specialist the big advantages are better informed patients and the reduction of preventable consults. The method is introduced in about 25% of the regions in the Netherlands. Over 2000 GPs use ZorgDomein. On the supply side, next to specialist care, ZorgDomein growingly also allows GPs the possibility to refer to mental health care organizations. In the nearby future (beginning of 2009) GPs can also refer patients to VV&T-organizations, (elderly/long term care) and diagnostic centers/laboratories and ZorgDomein will facilitate GPs to request for teleconsults by medical specialists.
Funding
No external funding. Demands for funding were declined after which the shareholders have decided to invest themselves.
Interoperability and standards
ZorgDomein is positioned between ‘extramural and ‘intramural’ information systems. Therefore a product like ZorgDomein works best when it is integrated with these systems. ZorgDomein’s underlying principle is that the care providers’ workflow and therefore the patient treatment process is leading for computerization and the choice of partnerships. One of the major interoperabilities ZorgDomein worked on is the connectivity with all the GP information systems in the Netherlands (for easy sign on, data-transfer of patient being referred). In 2005 started connectivity with suppliers of hospital information systems, leading to interoperability with 3 suppliers (for integrating the referral letter in the EPD/electronic patient files and allowing GP’s and patients to book appointments directly via the internet). Recently ZorgDomein also started building interoperability with radiology IS and laboratory IS. Furthermore some interoperability is being achieved depending on special wishes of clients (f.i. with teleconsultation-applications).
Timescale
Start of planning
1997
1st milestone
1997, birth of the Referral Model. Implementation in first region.
2nd milestone
October 2001, first presentation of the ZorgDomein application to a group of users (GPs and medical specialists) in Leiden, the Netherlands.
3rd milestone
2007, the 2000th GP works with ZorgDomein
Start of routine operation
2001
Evaluation
Ongoing
Characteristic of the application
Country
The Netherlands
Part in the healthcare chain
Diagnosis
Level of Implementation
Country-wide
Technology
Customised solution
Details on Technology
IBM servers in a datacentre. Linux Suse enterprise edition 9 as operating system. Cisco Firewall PIX 515.ASP (Java)application with an Oracle database ( 10.2.0.4). Secured E-mail is sent by IPSec VPN connections (3DES 168bits encrypted)Data encrypted with SSLDirect logging in from general practitioners information system is possible Main interoperabilities are: - HIS (GP’s information system)Relevant medical data are extracted from the HIS to ZorgDomein. The HIS will automatically updated with the relevant referral data.. - ZIS-EPD (Hospital Information Systems)The referral letter of ZorgDomein can be integrated with the Hospital electronic patient file. - ZIS-appointment systemThe patient can make an appointment by phone, internet of by a personal visit to the hospital - RIS (radiology information system)The application form can automatically be sent to the care provider. The GP’s will receive a copy of it in his HIS. - Lis (laboratory information system)By means of the ICPC code the GP fills in the application form. The GP sends the form automatically by ZorgDomein. The form will be absorbed by the labsystem. The GP’s will receive a copy of the form in his HIS.
Results
Outcomes
- Reduction of the unnecessary hospital visits up to 60% of the visits in patient groups affected - A reduction of unnecessary urgent-referrals up to 59% of total urgent-referrals - A reduction of second and third consultation visits to specialists up to 45% of the consultations in patient groups affected leading to shorter access times and increase of productivity (Maljers & Balestra, Medisch Contact 2001, more references below)
Wider impact
- GPs get insight in access times and care products between hospitals, rapid feedback after referral and reduction of unnecessary telephone calls. - Patients are better informed of the route and interventions in the hospital. - Shift in regional patient flows towards medical specialists which supply shorter access time and/or more service for patients.- Qualitatively better information transfer of GPs to specialist care (referral letters). - A better decision by GPs of when to refer a patient and when not- A shorter in time diagnostic process in hospitals by optimization of internal logistic In general: More efficiency in (integrated) care results to quality improvement and cost reduction for the care system as a whole.
Results expected?
Seeing that ZorgDomein was not externally funded, expectations were based on positive business cases. From the beginning we foresaw that a successful implementation in a region would grant a profitable business for other care organizations would enter the channel. The financial targets and the impact are being achieved however much slower than expectations, mainly because of the long proces of decisionmaking in regions between the hospital, the specialist board and the GP-institution. (because of the complexity to implement and change processes and application integration)
Success factors
- Happiness is the key to success. If you love what you are doing, you will be successful - Patience, patience, patience - Continuity of care - The introduction of competition in Dutch healthcare: The GP/ZorgDomein growth in strategic value for hospitals and other care institutions. - Close cooperation with end users combined with Rapid Application Development (first years) - Solving actual problems for users - Integration with existing ICT systems - Learning the ‘ways of the field’; i.e. understanding and being able to influence the decision making process.
Failure factors
- Not enough volume: an implementation that is too small (not enough GPs, not enough specialists) leads to not enough value in the system for GPs and specialist. - The feeling some GP’s have that working with ZorgDomein leads to profits at the hospitals of which they don’t benefit enough. Claim for compensation. - The introduction of competition in Dutch healthcare: The business model of ZorgDomein comprises the supply-side that pays for presentation on the system. This supply-side are mainly the hospitals. Investing in ZorgDomein therefore is an opportunity to bind GP’s, however some hospital administrations feel like they invest in their own competition. - Parallel systems: all current referral agreements (with all other care providers) must be caught within ZorgDomein otherwise the GP gets confused with different referral systems. In that case the working method doesn’t last.
References
References and dissemination
o Trefzeker verwijzen met Friesland ;Augustus 2008 o Nieuwsbrief Vice Versa ;juli 2008 o ZorgDomein nu beschikbaar via het landelijk besloten netwerk ZorgConnect van KPN Persbericht KPN mei 2008 o Nieuwsbrief Vice Versa ;maart 2008 o Nieuwsbrief MCRZ 5 maart 2008 o 25000ste verwijzing via ZorgDomein in regio Den Haag ;Zorgkrant januari 2008 o Transmurale nieuwsbrief MCRZ deel 4 2007 o Nieuwsbrief Promedico VDF juni 2007 o Nieuwsbrief Groene Hart Ziekenhuis juni 2007 o Specialisten en huisartsen maken honderd afspraken over online verwijzen MCRgaZet april 2007 o Regio Zuid-Oost Brabant koploper in Nederland: 100.000e verwijzing via ZorgDomein Nieuwsbrief Stichting Zorgverwijzing 2007 o Convenant getekend tussen huisartsen en CWZ Nijmegen De Brug 2007 o CWZ helpt huisartspatiënt sneller De Gelderlander 2007 o Transmurale nieuwsbrief MCRZ deel 2 2007 o Transmurale nieuwsbrief MCRZ 2007 o MCRZ introduceert online verwijzen in Rijnmond MCRGaZet 2007 o 100.000 internetverwijzingen via ZorgDomein Trompetter 2007 o Honderdduizend keer via ZorgDomein Eindhovens Dagblad 2007 o 't Lange Land Ziekenhuis: unieke koppeling ZorgDomein en ePointment 2007
Languages
Dutch
Organisation implementing
Title
Msc
Forename
Walter
Surname
Balestra
Organisation
ZorgDomein Nederland BV
Department
Occupational background
CEO, CIO, CTO
Address of organisation
H.J.E. Wenckebachweg 2001096 AS AmsterdamThe Netherlands
back
print
export DOC
export PDF
top