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Appl Clin Inform. 2011 Dec 28;2(4):546-64. doi: 10.4338/ACI-2011-06-RA-0039. Print 2011.

Introduction of electronic referral from community associated with more timely review by secondary services.

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National Institute for Health Innovation , The University of Auckland.



Electronic referral (eReferral) from community into public secondary healthcare services was introduced to 30 referring general medical practices and 28 hospital based services in late 2007.


To measure the extent of uptake of eReferral and its association with changes in referral processing.


Analysis of transactional data from the eReferral message service and the patient information management system of the affected hospital; interview of clinical, operational and management stakeholders.


eReferral use rose steadily to 1000 transactions per month in 2008, thereafter showing moderate growth to 1200 per month in 2010. Rate of eReferral from the community in 2010 is estimated at 56% of total referrals to the hospital from general practice, and as 71% of referrals from those having done at least one referral electronically. Referral latency from letter date to hospital triage improves significantly from 2007 to 2009 (p<0.001), from a paper referral median of 8 days (inter-quartile range, IQR: 4-14) in 2007 to an eReferral median of 5 days (IQR: 2-9) and paper referral median of 6 days (IQR: 2-12) in 2009. Specialists upgrade the referrer-assigned eReferral priority in 19.2% of cases and downgrade it 18.6% of the time. Clinical users appreciate improvement of referral visibility (status and content access); however, both general practitioners and specialists point out system usability issues.


With eReferrals, a referral's status can be checked, and its content read, by any authorized user at any time. The period of eReferral uptake was associated with significant speed-up in referral processing without changes in staffing levels. The eReferral system provides a foundation for further innovation in the community-secondary interface, such as electronic decision support and shared care planning systems.


We observed substantial rapid voluntary uptake of eReferrals associated with faster, more reliable and more transparent referral processing.


User acceptance and resistance; process improvement; provider-provider communications

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