Case: eReferral of legally reportable conditions to Medical Officers of Health (eNotification)

Type: This case is a special type of eReferral.

Summary of the problem:

1. All NZ registered physicians are required to refer patients diagnosed with one or more of the 50 or so conditions designated as "notifiable disease" to the Medical Officer of Health (MOsH) for the district in which the case resides.  The current list of legally mandated referrals is available here http://www.moh.govt.nz/moh.nsf/wpg_index/About-notifiable+diseases.  The purpose of these referrals is to enable Medical Officers of Health and their public health services to provide additional service to the patient and their family in order to prevent spread of the disease; to investigate the source of the infections such as contaminated food so as to prevent further cases, to identify well individuals who may have been exposed to the agent causing the condition for whom preventative services may be provided; and to monitor population level trends in the occurrence of these conditions.
2. In order to triage and prioritize investigation and management of these referrals public health physicians and their teams require certain demographic, risk factor and clinical data about cases.  The current referral process often results in the provision of insufficient information on the initial referral for this triage to take place.  As a result public health services are required to devote significant resources to contacting referring physicians by phone to collect missing information about cases.  For more common diseases such as Campylobacteriosis public health staff do not have sufficient resources to call all referring physicians and letters to patients are used to try and collect missing information.  The response rates to such letters are often very low and the responses are not sufficiently timely to enable timely public health action.  This means that cases that may require urgent follow-up because of a risk of transmission in a work place or school setting may not be identified in a sufficiently timely manner.
3. An automated referral process based on HL7 messages from laboratories to a web based national notifiable disease database (EpiSurv) has been established and is partially implemented.  These referral messages do not however contain sufficient clinical or risk factor data to enable Medical Officers of Health to triage cases.  Important data elements required for triage of referrals include occupation (or workplace) of the patient and immunization status for vaccine preventable disease cases.  Potentially vaccination status is available through the NIR but this currently requires a manual look up by public health staff.
4. Not all reportable conditions are detected through laboratory testing and often referral is required prior to laboratory confirmation being available (eg for cases of vaccine preventable conditions such as measles).  In some instances the referring physician will also wish to consult the Medical Officer of Health to obtain advice regarding immediate investigation and management at the time of initial diagnosis.  In these instances the GP (or other referring physician) will often call the Medical Officer of Health and because of this be called upon to provide required referral data by phone.  Referring physicians often find this process of manually passing on data that already existings within the patients ECR frustrating.  
5. Many of the required data fields also constitute a national minimum dataset for the national collection of all referred cases.  The required data elements for each condition have been agreed nationally and are specified here http://www.surv.esr.cri.nz/episurv/crf.php. 
6. Not all data elements from the national dataset are drawn from the referring physician as some data are provided by the Medical Officer of Health after investigation and service provision by public health.
7. Time frames for referral also vary by condition with some conditions requiring urgent referral and management by public health.  Systems must be in place to ensure urgent referrals are always reviewed by a Public Health Physician in a timely fashion.  Diagnosing physicians may be hospital based physicians working overnight and a process for referring patients afterhours would be preferable to the practice of relying on handover to another staff member to refer cases during work hours.

Requirements

The challenge is to create a solution that streamlines the referral process for reporting doctors and ensures sufficient information is provided within the initial referral to enable MOsHs to prioritize and manage referrals efficiently and safely.

The solution will:

1. build on existing infrastructure by integrating the referral process with: existing eReferral protocols, the existing web based national reportable conditions data collection and reporting tool (EpiSurv); and local case management tools such as the NDCMS developed by ARPHS.
2. develop an interface for populating missing required data fields within the reporting physician's PMS (or clinical workstation for hospital physicians)
3. integrate data streams and records created through the laboratory reporting process with records generated for the same patient by a referring doctor.
4. provide for two way communication between Medical Offier of Health and referring doctor and include an acknowledgement message to be sent to referring physicians once the referral triage process has taken place
5. potentially include a notifiable disease specific version of an eDischarge once the case has been managed.

The successful vendor will work with a group of Medical Officers of Health and the EpiSurv system owner ESR to refine the eReferral requirements including:

• identifying critical data elements, alert requirements such as SMS notification, receipt and acknowledgement processes

See the Powerpoint Presentation (1.53MB,PDF)