Imagine your favorite football team is in a real neck-to-neck with another team, and the game could tip in anyone’s favor. It is the last minute, and in an insane turn of events, the quarterback throws the ball in the air, hoping the player in the end zone could make a touchdown. Instead, the reckless throw results in confusion, the guy in the end zone get tackled, and the game ends in disappointment.

Now, let’s step out of football and look at these statistics that show a little picture of referrals in healthcare:

  • Only about 50% of referrals result in a completed appointment
  • Less than 25% of referrals are completed as intended by the referring provider
  • 55% of specialist visits are unnecessary.
  • 60-70% of referrals go unscheduled

Did you notice any similarities?

In case one, the player didn’t score a touchdown, and in the second case, the patient didn’t end up with the right provider and the treatment. The reason being the process— a reckless throw and an inefficient referral procedure.

Most healthcare organizations lose about 30% to 60% of patients on account of inefficient referrals. Value-based care is expected to become the leading payment model by the year 2020, and healthcare organizations cannot afford losing more than half of their revenues due to reduced referral leakages.

How do you know that your referral management needs healing?

Imagine a situation where a patient, in his early 60s, suddenly suffers from severe abdominal pain. He goes to his doctor, and the doctor directs him to a specialist she knew out of her professional knowledge.

Now the situation can unfold in many ways, where the patient might end up getting treated or the exact opposite of it. In all the scenarios, the part where things might go wrong is the process of referring the patient. The problems that these stakeholders might face include:

  • The inability to identify in-network providers
  • Lack of proper patient information
  • Limited access to information flow among providers
  • Reliance on age-old techniques of fax-based referrals

… and many more.

Now the question is: ‘What is the solution?’

It all boils down to just one thing— having the right data. Imagine you visit your doctor. The moment you tell him your problem, he looks into his screen to look for the right specialist. In just one click, he gets all the correct specialists in a listicle format. And all he has to do for the rest of the story is just click on the ‘Refer’ button.

Seems undoable? Actually, all we need is a data-driven strategy.

  • Don’t just plan your data but also your approach

It is never about just knowing the patients but understanding them, their health, their socio-economic condition, and their care journeys. All of this is not possible if we do not have access to the right data. Whether it be a lab test or spiking blood pressure— nothing should be left undetected.

  • Easier it is for providers to understand, efficient will be the referral

You cannot expect the rest of the process to be perfect if the beginning is imperfect. If the provider is stuck finding the information, not only will this delay the referral but also increase the chances of errors. What they need is a single screen view of specialists in a list that includes every detail such as geography, specialist ranking, availability, and fees, among others.

  • Connecting communities and care teams to deliver the best care

It is crucial that care teams and communities remain aware of the events happening in the patients’ care journeys. They need a streamlined tracking of patient referrals at the clinical or patient level. It will reduce the turnaround time for escalations.

  • The patient lost in the process is the revenue lost

The right referral strategy includes two significant aspects:

  • Increasing the visibility into the process to the patient
  • Using advanced analytics tools to develop a lens into the referral process

What they need is a simple reminder that enlists all the details regarding the visit and gives timely updates to them regarding the specialist and the appointment date. Organizations can increase patients’ access to telehealth services by allowing plans to propose the use of telehealth services instead of promoting in-person visits.

What is the secret recipe to achieve this?

The secret recipe for the best referral process includes three primary ingredients:

  • Stakeholders
  • Right data
  • Right technology approach

The entire process starts with three major stakeholders- providers, patients, and leadership. Most of the time, they are not in sync with each other regarding the entire referral process. It is essential that they remain connected with each other during the whole care journey. The patient should be well-aware of the specialist he is being referred to, the appointment details, and the entire procedure. At the same time, providers, both the PCP and the specialist, should be on the same page about the patient. In this entire story, leadership plays one of the most important roles. They are responsible for ensuring that every process is carried out in the most streamlined and hassle-free manner.

Once we are all set with the stakeholders, then comes the turn of bringing the right tools at their disposal. This step starts with having the right patient data. Whether it be the patient’s clinical data or lab results or social determinants of health or any other relevant data, it should be well-integrated into the providers’ workflows.

After having this data, we can automate the entire process. The PCP gets all the details about the patient and the specialist right on his screen. In just one click, the details about the referral should be sent to the specialist and the patient, their calendars should be booked, care teams should be made aware of this entire event, and the data should be automatically modified as per the specialist’s requirement to enable him to spend more time with the patient.

The road ahead

If I had said a decade back that value-based care is on the rise and healthcare is moving towards patient-centricity, it would have been thought-provoking. However, now it is just a fact— the fact that everyone is trying to realize. Like other domains, AI and Machine Learning are revolutionizing the healthcare space and every activity associated with it; and referral management is not untouched. A perfect, AI-enabled referral management process is not just about plugging network leakages. It is about creating a ‘culture of wellness’ for patients where they can feel safe and ensure that whatever health care they will receive is holistic and quality-oriented.

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Abhinav Shashank is the CEO and Co-Founder at Innovaccer , one of the fastest growing big data and analytics company based out of silicon valley. Innovaccer recently raised $15.6 million Series A led by Westbridge Capital Partners.

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