Published: 03/11/2005 Volume 115 No. 5980 Page 8 9

The Cheshire-based e-booking system that responds to GP referrals in three seconds sounds ideal, but choose and book is set to kill it. Daloni Carlisle finds out what we will be missing

An electronic referral system that is fast, secure, dynamic, works at the touch of a button and can link with any GP IT system. Does this sound like a fantasy?

It is actually up and running at Countess of Chester Hospital foundation trust in Cheshire, which is now receiving 2,600 e-referrals a month to its outpatient clinics and radiology department. That is more than a quarter of all referrals received by the hospital. Its designers claim it is the UK's largest such scheme.

The only fly in the ointment is that it will not last long. Choose and book is set to supersede the system for the 30 English GP surgeries currently using it. Only Welsh GPs - whose patients make up about 20 per cent of the hospital's workload - will continue to use the system.

The e-referral system in place at the Countess of Chester Hospital was designed by the clinical correspondence specialists Medisec Software, better known for providing electronic discharge summaries.

'We have been working with Medisec on improving our communication with GPs for about six or seven years, ' says Patricia Reilly, clinical systems manager at the hospital. 'We send out pathology results, radiology results, accident and emergency summaries and discharge summaries electronically. The e-referral system is an attempt to close the loop by allowing GPs to refer to us.' Medisec managing director Tom Rothwell explains how it works. 'At the moment making a referral involves generating a letter and sending it by post. It gets lost. Or it arrives at the hospital and gets sent to the wrong department, ' he says.

'Essentially we have put in place a management process.' When a GP makes a Medisec e-referral, the system generates a pre-set form that asks for relevant information about the patient - name, NHS number, clinical details, the specialty to which they are being referred and so on. As it works from within the practice's IT system, some of this is automatically generated.

Three-second success

The system mandates the sender to provide certain information, says Mr Rothwell. 'For example if the GP is referring a cardiology patient, the form will ask for blood pressure and cholesterol levels.' Clinicians, GPs, the hospital IT department and Medisec designed all these templates jointly.

Once complete, the GP hits a button and zoom, off it goes. Three seconds later, There is an acknowledgement from the hospital.

'All the GP systems we are familiar with use Microsoft Word.

We have simply put a command button on the Word document that allows GPs to post the referral out of the Word file and into the hospital, ' says Mr Rothwell. 'It is a single click.' The referral is transferred to the hospital server using a secure website, Medisec NET. 'E-mails are not reliable or secure, ' explains Mr Rothwell. 'Using a website, the hospital system is able to tell the GP that the referral has arrived and the document is secure.' If the form is incomplete the system will ask for the correct fields to be filled in before accepting the referral.

Dr David Morris, a GP at St Mark's Dee View surgery in Flintshire, Wales, is an enthusiastic user. 'The patients love seeing the flash, confirming that the hospital server has received the referral before they get up from their chair in my consulting room, ' he says.

It is all a far cry from waiting weeks for a letter.

At the hospital, the referral is again automatically managed - sent to the correct department where it can be prioritised by the consultants or forwarded to the right place for a test to be arranged. 'We have designed it around the hospital workflow, ' says Mr Rothwell.

Ms Reilly adds: 'It gives our consultants far more information to make decisions about patient care.' And because It is web based, GPs can log in from their practice and track the progress of individual patients.

Entering details onto the hospital's patient administration system is semiautomated. Mr Rothwell says: 'When a referral arrives the system will automatically search for the NHS number say, or the name. Then there is a human intervention to say 'yes, this is the right person' before the details are added automatically to their record. It maintains the human intervention but reduces the scope for human error.' The hospital is delighted with the system, says Ms Reilly, and currently going through a benefit realisation programme to find out how much the trust is saving.

'We can't release any results yet but we do expect some savings not just from the e-referrals but from the wider Medisec clinical communication, ' she says.

At one end of the spectrum are printing and paper costs - 12 practices now receive A&E summaries in electronic form only.

But there may also be advantages for waiting-list management as consultants are receiving better clinical information.

Of the 33 practices using Medisec e-referral, most are from Cheshire West primary care trust. Laura Maddock, acting head of primary care, lists its benefits. 'It is secure. The information reaches the hospital almost instantaneously. The hospital does not have to retype information so it reduces error. It has an audit trail built in. It costs the PCT and GP surgeries nothing as the system is maintained by the hospital.'

But, she adds: 'It is a local solution and could not be used for referrals to other hospitals. We have quite a big patch, and where practices are referring to more than one trust they are having to use a different solution for each.' Not only is the PCT under pressure to provide a single solution, but the advent of choose and book is also ringing the death knell for Medisec's e-referral in England at least.

Cheshire West PCT is now switching over to indirectly bookable services (IBS), which is part of choose and book, but requires the patient to call the hospital and confirm the booking.

Referral focus

Ms Maddock says: 'We expect the Medisec system to be phased out, although how long that will take remains to be seen. It is a shame because in many ways it is more advanced than IBS.' Mr Rothwell, not unexpectedly, agrees. 'This system concentrates on e-referral, ' he states. 'Choose and book has tended to focus very much on the choosing and the booking without paying much attention to the referral part.' The switch to choose and book will impact on the system's development. 'The next step would have been to use it as a workflow practice for the whole of the referral but we have stopped where we are at the moment because of choose and book, ' says Ms Reilly.

However, she promises that the Welsh GPs using the system will not be abandoned. 'Twenty per cent of our patients are Welsh and this will continue to be the solution for them, ' she says. That will be music to Dr Morris's ears. 'We really wouldn't want to do without it, ' he says. The proportion of patients coming from Wales should be enough to justify the hospital keeping the system going, he says. 'And the electronic referrals is just one part of Medisec. The other parts are not dependent on or competitors with choose and book. So I do not think There is a threat.' NHS Connecting for Health defends the functionality of choose and book. 'The procurement of choose and book and the contracts that are in place have been praised by independent reviewers... We have no doubt choose and book delivers the best value electronic booking solution to the NHS, ' says a spokesman.

He adds: 'There are many elements to the national IT programme, which will be delivered in coming years. In order to get the maximum value out of these systems it is important that they are seamlessly integrated. This would be an impossible task if many different systems were operating locally.

'Having one common electronic booking system implemented in GP surgeries and trusts will not only help ensure the delivery of all components of the national programme, but also reduce costs. Costs associated with ongoing maintenance, upgrades and training will be reduced through the delivery of a common electronic booking system.

'Hence, while tactically the Countess of Chester's e-referral scheme may be effective, in the long term a single electronic booking system across all trusts will deliver wider benefits and economies of scale to the NHS.' GPs may be convinced by this once they can refer with a single click, and get an answer in three seconds. .

This week HSJ has launched a new online Good Management service for readers. If you would like to find out more specific information about choose and book, please visit wwwgoodmanagement-hsj. co. uk/ chooseandbook

Key points

A sytem developed at Countess of Chester Hospital foundation trust refers 2,600 patients a month electronically.

GPs fill in a pre-set form on word and transmit it with a single key. The hospital acknowledges receipt in three seconds.

Choose and book will see the sytem phased out, except for GPs in Wales.