title: Beneath the tip of the iceberg: using electronic referrals to map the unquantified burden of clinical activity in a urology service.
abstract: BACKGROUND
  The aim of this study was to inform health policy by demonstrating the benefits of an electronic referral (e-referral) system to study inpatient referrals to urology departments.
  
  
  METHODS
  London North West Healthcare NHS Trust has over 800 beds and several secondary and tertiary care services. In January 2014, we designed an e-referral form to requisition urology input for in-patients using the Integrated Clinical Environment™(ICE) platform. We retrospectively reviewed e-referral records from February to December 2014 for patient demography, the referring service and disease groups triggering a referral.
  
  
  RESULTS
  There were 1192 referrals. There was a median of 107 e-referrals per month (IQR 97-123, range 91-132) and 4 per day (IQR 2-6, range 0-12). Weekend e-referrals were 127 (median 1, IQR 0-2, range 0-5) with 1065 e-referrals on weekdays (median 4, IQR 3-6, range 0-12). A total of 848 (71.1 %) patients were male, and 344 (28.9 %) were female. Patients' mean age was 63 (SD 21) years. Almost half (550, 46 %) were acute referrals. Amongst the acute referrals, the majority (466, 84.7 %) arose from A&E. From the non-acute conditions, 381 (59.3 %) patients were from the medical specialities and 246 (38.3 %) from surgical disciplines. The three largest disease categories were urolithiasis (287, 24.1 %), haematuria (185, 15.5 %) and for ex-catheterisation (102, 8.6 %). A qualitative review showed the strengths and weaknesses of the system, enabling improvements in operational efficiency.
  
  
  CONCLUSIONS
  An e-referral system monitors activity accurately. Systemic improvement in referral pathways would lead to better patient care and enable services to factor in the unseen component of workload and prompt realistic staffing.
authors: Department of Urology, London North West Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK. deepakbatura@gmail.com.
authors: Deepak
authors: http://orcid.org/0000-0002-2833-1819
authors: D
authors: Batura
authors: Department of Urology, London North West Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.
authors: Tumaj
authors: T
authors: Hashemzehi
authors: Department of Urology, London North West Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.
authors: Tiffany
authors: T
authors: Lee
authors: Department of Urology, London North West Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.
authors: Krsna
authors: K
authors: Mahbubani
authors: Department of Urology, London North West Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.
authors: Munira
authors: M
authors: Ally
authors: Department of Urology, London North West Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.
authors: Malwina Julia
authors: MJ
authors: Figaszewska
authors: Department of Urology, London North West Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.
authors: Rajesh
authors: R
authors: Kavia
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057286:Electronic Health Records; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013043:Specialties, Surgical / Q000706:statistics & numerical data*; D014570:Urologic Diseases / Q000175:diagnosis / Q000628:therapy; D014573:Urology Department, Hospital / Q000706:statistics & numerical data*
keywords: Medical informatics applications; Online systems; Quality improvement; Referral; Remote consultation