Pembroke Pines, Florida-based Primary Care Offices was facing a few administrative challenges, and it knew it needed solutions to these problems if it were to most efficiently operate its clinic.

THE PROBLEM

The first problem the three-physician, primary care practice faced was that it had a tedious, error-prone and inefficient referral authorization process. There is a great number of payers and plans in its market, and each payer has its own portal for performing business operations.

Alternatively, a payer might use a multi-payer portal referral authorization and eligibility clearinghouse. This represents an additional information system that has to be maintained and used to perform regular business operations while accepting these payers and plans.

“In an ideal world we would never maintain two systems to perform a single operation,” said Kyle Knight, IT administrator at Primary Care Offices. “We had the physician order information in one EHR and the insurance request in the payer’s portal, completely unlinked. When you have unlinked, unrelated systems working together, the challenge is accuracy due to multiple entries of data.”

One single mouse click, checkbox or keyboard stroke is all it takes to cause an error, and these are systems where people’s medical care is concerned. High accuracy is critical.

"We just simply need to update or change the code and press resubmit. At least 3-4 minutes are saved here by not needing to re-enter all the information into the payer’s portal."

Kyle Knight, Primary Care Offices

“This process is error prone by design and could easily be improved upon with a well-developed interface,” Knight said. “So you can imagine this whole process, aside from being error-prone and tedious, imagine if something needs to be corrected or if additional information needs to be added to the referral. The whole process loop has to start over again.”

This was the second problem the clinic faced, having to repeat the whole process for a simple correction. “This happens more often than you might think,” Knight said. “Doctors add to orders or modify orders all the time.”

The third problem was a slow validation process.

“Sometimes we would do all the referral authorization and the specialist office would contact us to tell us something did not validate,” Knight said. “In the provider portal we would need to login and rekey all the information to validate that the information is accurate.”

PROPOSAL

Turning to health IT vendor Holon Solutions, now staff just opens the referral in the physician’s EHR and the previously submitted information automatically opens. The new technology saves a tremendous amount of time. This process of referral authorization is very common in insurance plans that are Medicare-based.

And with regard to having to repeat the whole process for a simple correction, Holon Solutions was able to mitigate this problem by having an interface that works with the clinic’s EHR. The interface enables staff to update their order on the physician-side system and simply press resubmit. Holon Solutions integration resends the information and retrieves the newly updated information within seconds. The previously slow correction process has been drastically improved, Knight said.

MARKETPLACE

There is a variety of vendors with referral authorization software on the market today. Some of these vendors include Agadia, ArchiTECH Solutions, EcoSoft Health, Referral SaaSquatch and Secure Exchange Solutions.

MEETING THE CHALLENGE

The only way to face the challenge of improving the referral prior authorization process given the complex systems and payers was to infuse technology-enabled automation as much as possible, Knight insisted.

“Automation of data entry was the solution,” he explained. “This could be described as reimagined-interoperability in the healthcare information technology world. This sort of technology already exists within the laboratory industry. We are able to send and receive lab results completely electronically; however, this didn’t exist for the referral authorization process.”

The sensor-based app technology primarily is used by the clinic’s referral coordinator, but it’s also used by office managers who process requests in emergency or STAT situations.

“This app was welcome,” Knight said. “The referral coordinators and managers were happy and understood the user interface immediately. From the initial two-minute demonstration, they were able to see the tremendous amount of time they would save and the reduction on manual data entry. Imagine having part of your job be reduced to a few clicks versus over fifty.”

Holon achieves this by integrating otherwise segregated systems behind the scenes. The app integrates the clinic’s EHR, the clearinghouse and the payer. The IT vendor developed an integration that in real time communicates between all the data channels so the challenge of the referral process is met, Knight said.

RESULTS

There are many significant achievements Primary Care Offices has made using the referrals app alongside its EHR:

• One referral coordinator per three physicians: One referral coordinator is able to manage referral requests for three physicians. In the past, it was one coordinator per physician. So a staff reduction from three to one.
• Improved quality and patient outcomes: In addition to staff reduction we have I, the clinic has increased the quality of the referral coordination process. By removing a lot of the grunt work of multiple systems with multiple redundancies in data entry, the referral coordinator is able to spend more time verifying records and carefully curating the patient’s care. “We are a value-based care organization, so we focus on the quality of the patient’s care as well as the cost involved,” Knight said.
• Office process redefined: The clinic was able to reassess the office workflow. The referral department now is centralized in the administrative office and managers do STAT referrals. This ensures the maximum efficiency for staff.
• Main referral coordinator works two to three weeks ahead of schedule: Because of the newly found efficiencies, the referrals coordinator stays comfortable 2-3 weeks ahead of the referral appointment schedule for patient satisfaction. This has led to patients having higher levels of success with their specialist appointments. This is something that is a challenge for managed care plans that require PCP authorization for specialist appointments, Knight remarked.
• Five-minute process becomes 25 seconds: “Statistically speaking, we have cut the process from five minutes to 25 seconds,” Knight said. “This is huge.”
• Workload stress reduced: Workload stress is reduced because of reduction of repetitious tasks. “This is because the process is easy with the Holon technology,” Knight said.
• 100% accuracy of data input: “We have also ensured 100% accuracy in data input,” Knight explained. “CPT and ICD codes can be very similar. Office visit codes such as 99214 or 99215 can have a huge implication and will make a world of difference to the specialist receiving the referral. To ensure accuracy, Holon displays the submitted data alongside the EHR system for increased assurance that the app automatically gathered the proper data.”
• Referral corrections in seconds: The most significant process improvement is the ability to make referral corrections in less than a minute, Knight said. Often a specialist office will call and need to add a CPT code or modify a CPT code. With the new technology, there is no reentry of data for a small error on the part of a requesting provider. “We just simply need to update or change the code and press resubmit,” Knight concluded. “At least 3-4 minutes are saved here by not needing to re-enter all the information into the payer’s portal.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com
Healthcare IT News is a HIMSS Media publication.