The Cwm Taf Community Dental Service (CDS) has previously used a paper system to refer patients to the orthodontic specialists within the Cwm Taf CDS. However, at the beginning of June 2019, an electronic referral system was introduced. Although electronic referrals have had a minimal effect on the overall waiting time for a patient, there has been an improvement in the efficiency of transfer of orthodontic referrals within the CDS. Electronic referral systems have reduced the number of inappropriate referrals, improved patient confidentiality and maintained an accurate record that is accessible from any of the Cwm Taf CDS clinics.
CPD/Clinical Relevance: The article highlights the benefits of an electronic referral system with respect to reducing both inappropriate referrals and waiting times.
Article
The Cwm Taf Community Dental Service (CDS) comprises 10 dental clinics based in the Rhondda Cynon Taff area. The service has previously used a paper system to refer patients to the orthodontic specialists within the Cwm Taf CDS. However, at the beginning of June 2019, an electronic referral system was introduced to replace paper referrals.
Nationally, there is an aim to adapt to an electronic referral system for medical referrals within the NHS. Regarding orthodontics in Wales, there is an objective to reduce waiting lists and prioritize patients to ensure they receive a high standard of care.1 Electronic management systems have been shown to reduce the number of inappropriate referrals because there is a greater element of control compared with paper-based referral options.2 Reddy et al.3 showed that inappropriate referrals lead to patient dissatisfaction and inefficient use of clinical time.
The electronic referral system used by the Cwm Taf CDS is operated by Faculty of Dental Surgery (FDS) consultants. After the dentist has submitted an orthodontic referral, it is received and triaged appropriately by CDS orthodontic specialists. If deemed appropriate, the patient is placed on the waiting list for an initial orthodontic assessment with the orthodontic specialist within the clinic that is closest to the patient's home address.
Aims and objectives
This study aimed to compare the electronic and paper referral systems used within the Cwm Taf CDS. It aimed to assess the success of each system with relation to ensuring internal orthodontic referrals are appropriate and waiting times for patients are reduced.
Specifically, the objectives were to:
Determine whether electronic referrals have reduced the number of inappropriate orthodontic referrals
Assess whether electronic referrals have reduced the length of time between referral to treatment (RTT)
Materials and methods
In the period April–May 2019, 50 patients were randomly selected to represent the sample for referrals via the paper system. Similarly, 50 patients were randomly selected from the period June–July 2019 to represent the sample for referrals via the electronic system. The same data collection sheet, designed for use in Microsoft Excel, was used to record the data for both samples.
Inappropriate orthodontic referrals
Orthodontic referrals were recorded as inappropriate if the patient had not been added to the waiting list for an initial orthodontic assessment after triage. These patients had been deemed unsuitable for NHS orthodontic treatment in a community dental setting for various reasons.
Referral to treatment (RTT)
It must be noted that the length of time that a patient remained on the waiting list to receive an initial orthodontic assessment was the same, regardless of whether the referral was submitted electronically or by paper. However, the length of time between submission of the referral by the dentist to the patient being placed on the waiting list can vary between systems.
For electronic referrals, the date on which the referral was submitted by the dentist could be found on the referral system. For paper referrals, the submission date could be found in the patient's notes. For both electronic and paper referrals, the date that the patient was placed on the waiting list was found under the ‘Waiting lists’ tab on the SOEL (Software of Excellence) Health management computer software.
The number of days between submission of the referral by the dentist to the patient being placed on the waiting list for an initial orthodontic assessment was recorded. Monday to Friday were used as working days while weekend days and bank holidays were excluded. For example, a referral submitted on a Friday and placed on the waiting list the following Monday would be recorded as taking 1 day to complete.
Results
Inappropriate orthodontic referrals
Of the 50 electronic referrals sampled, none was found to be inappropriate. However, of the 50 paper referrals sampled, four were found to be inappropriate. Of these four patients, two required treatment in a hospital setting and two had mild aesthetic issues that did not qualify for orthodontic treatment on the NHS (IOTN of less than 3.6).
Referral to treatment (RTT)
The number of days between submission of a referral by the dentist to the patient being placed on the waiting list for an initial orthodontic assessment is shown in Table 1.
Referral
Length of time (days)
Number of patients
<1
1–2
>2
Electronic
37
11
2
50
Paper
12
17
21
50
Discussion
Inappropriate orthodontic referrals
The new electronic referral system eliminated inappropriate orthodontic referrals. This is largely due to the restrictions within the electronic referral system. The dentist cannot successfully submit the referral unless the patient has reached the desired criteria for acceptance in a community dental setting.
For example, if the dentist indicates that the patient has a cleft lip/palate, craniofacial syndrome or any other complex or congenital medical condition, the referral will be automatically rejected and diverted to a hospital setting. Furthermore, the main presenting problems must be ticked following the MOCDO principle. This acronym (Missing teeth, Overjet, Crossbites, Displacement of contact points, and Overbite) guides the observer to the single worst trait of the malocclusion. If the dentist ticks only features that score below an IOTN of 3.6, the referral system will not allow submission. However, there is a loophole. If the dentist ticks the box entitled ‘assessment of 6s' as an opinion on an extraction pattern of poor prognosis, 6s qualifies for acceptance.
In addition, the system will prompt for the necessary radiographs and will not allow submission unless they are attached.
Referral to treatment (RTT)
The electronic referral system has, so far, reduced the length of time between referral submission and placement of the patient on the waiting list for an initial orthodontic assessment. Paper referrals were sent by internal mail, which could take up to 5 working days to be delivered. Electronic referrals have improved the efficiency of transfer of referrals within the CDS.
However, the length of time that the patient is on the waiting list to receive an initial orthodontic assessment has remained the same, regardless of whether the referral was submitted electronically or by paper. Over 90% of orthodontic referrals within the CDS comply with the 18 week RTT pathway. Therefore, the length of time taken between referral submission and placement of the patient on the waiting list will have minimal effect on the overall waiting time for the patient.
Conclusions
Overall, the electronic referral system is far more detailed than the paper system. It is completed in stages that ensure ease of use for the referring dentist. Inappropriate referrals are rejected before submission to allow the dentist to refer to a hospital or private practice as required, preventing wasted waiting time for the patient.
Although electronic referrals have had a minimal effect on the overall waiting time for a patient, there has been an improvement in the efficiency of transfer of orthodontic referrals within the CDS.
Electronic referral systems have reduced paper waste, improved patient confidentiality and maintained an accurate record that is accessible from any of the Cwm Taf CDS clinics. All NHS referral systems should move to an electronic referral system to improve the efficiency of services.
