{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T23:00:01Z","timestamp":1785538801117,"version":"3.56.0"},"reference-count":17,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,7,1]],"date-time":"2025-07-01T00:00:00Z","timestamp":1751328000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,7,1]],"date-time":"2025-07-01T00:00:00Z","timestamp":1751328000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"This quality improvement project was funded by the Emory Department of Medicine, FAME (Fostering the Academic Mission in the Emory DOM) grant.","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Health Serv Res"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>In the United States, more than a third of patients are referred to specialists each year; however, most of these referrals do not lead to completed appointments. At the Grady Health System (GHS), our large safety net hospital system, the initial gastroenterology (GI) referral process suffered from multiple inefficiencies, creating barriers to care. We aimed to improve GI referrals with both a triage and a direct-to-endoscopy program to relieve systemic barriers to GI care at GHS especially around colorectal cancer screening.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Given wait times for GI services and employee dissatisfaction with navigating patients through the referral process, a GI smart order set was built using the Epic electronic medical record. The process took 8 months and included automated anesthesia screening as well as periprocedural guidance on blood thinners. We measured time from placement of referral for screening colonoscopy to scheduling of the screening colonoscopy to assess improvement in wait times for GI services.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Key results<\/jats:title>\n                    <jats:p>In our pre-implementation survey, 60% of providers placed at least one urgent referral a month, and 55% of providers were either somewhat or very dissatisfied with the referral process. This led to the creation of multiple unofficial and only partially successful bypasses to expedite GI care. With the new GI smart order set, there was a 93% reduction over 12 months in the time from providers screening colonoscopy referral request to procedure scheduling from an average of 422 to 28 days. In addition, overall rates of colorectal cancer screening increased approximately 6% from 43.5 to 49% since the order set was implemented.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This novel outpatient GI referral smart order set addressed multiple barriers to care and created a novel triage mechanism as well as a direct-to-endoscopy referral stream. This model can be used to improve triaging and increase access to GI and other specialist services.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12913-025-12976-3","type":"journal-article","created":{"date-parts":[[2025,7,1]],"date-time":"2025-07-01T04:26:45Z","timestamp":1751344005000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Developing user-friendly ambulatory referrals: a quality improvement study in GI referral services at a large academic safety net hospital system"],"prefix":"10.1186","volume":"25","author":[{"given":"Aaron Gerard","family":"Issac","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wendy","family":"Du","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alix","family":"Youngblood","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wilhelmina","family":"Prinssen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelly","family":"Carroll","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Geller","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Palak","family":"Patel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bhavin","family":"Adhyaru","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason","family":"Brown","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,7,1]]},"reference":[{"issue":"1","key":"12976_CR1","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1111\/j.1468-0009.2011.00619.x","volume":"89","author":"A Mehrotra","year":"2011","unstructured":"Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the united States. Milbank Q. 2011;89(1):39\u201368.","journal-title":"Milbank Q"},{"key":"12976_CR2","doi-asserted-by":"publisher","first-page":"715","DOI":"10.1007\/s11606-018-4392-z","volume":"33","author":"MP Patel","year":"2018","unstructured":"Patel MP, Schettini P, O\u2019Leary CP, Bosworth HB, Anderson JB, Shah KP. Closing the referral loop: an analysis of primary care referrals to specialists in a large health system. J Gen Intern Med. 2018;33:715\u201321.","journal-title":"J Gen Intern Med"},{"key":"12976_CR3","unstructured":"U.S. Preventive Services Task Force. Colorectal Cancer: Screening [Internet]. www.uspreventiveservicestaskforce.org.2021. Available from: https:\/\/www.uspreventiveservicestaskforce.org\/uspstf\/recommendation\/colorectal-cancer-screening"},{"key":"12976_CR4","unstructured":"National Cancer Institute. Cancer of the Colon and Rectum - Cancer Stat Facts [Internet]. SEER. 2023. Available from: https:\/\/seer.cancer.gov\/statfacts\/html\/colorect.html"},{"issue":"5","key":"12976_CR5","doi-asserted-by":"publisher","first-page":"614","DOI":"10.1007\/s11606-009-0955-3","volume":"24","author":"Y Kim","year":"2009","unstructured":"Kim Y, Chen AH, Keith E, Yee HF Jr, Kushel MB. Not perfect, but better: primary care providers\u2019 experiences with electronic referrals in a safety net health system. J Gen Intern Med. 2009;24(5):614\u20139.","journal-title":"J Gen Intern Med"},{"issue":"1","key":"12976_CR6","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1038\/sj.bjc.6604096","volume":"98","author":"E Mitchell","year":"2008","unstructured":"Mitchell E, Macdonald S, Campbell NC, Weller D, Macleod U. Influences on pre-hospital delay in the diagnosis of colorectal cancer: a systematic review. Br J Cancer. 2008;98(1):60\u201370.","journal-title":"Br J Cancer"},{"issue":"3","key":"12976_CR7","doi-asserted-by":"publisher","first-page":"195","DOI":"10.5455\/msm.2015.27.195-199","volume":"27","author":"M Naseriasl","year":"2015","unstructured":"Naseriasl M, Adham D, Janati A. E-referral solutions: successful experiences, key features and challenges-a systematic review. Materia socio-medica. 2015;27(3):195.","journal-title":"Materia socio-medica"},{"key":"12976_CR8","unstructured":"Page CL. and L. 20 Largest Public Hospitals in the United States [Internet]. www.beckershospitalreview.com. 2011 [cited 2024 Feb 8]. Available from: https:\/\/www.beckershospitalreview.com\/lists-and-statistics\/20-largest-public-hospitals-in-the-united-states.html"},{"key":"12976_CR9","unstructured":"Georgia Health Policy Center. Grady Community Health Needs Assessment. Available at: https:\/\/www.gradyhealth.org\/wp-content\/uploads\/2018\/04\/GHS-Community-Health-Needs-Assessment-2016.pdf"},{"key":"12976_CR10","unstructured":"Care Across the Continuum.| Epic [Internet]. www.epic.com. Available from: https:\/\/www.epic.com\/software\/care-across-the-continuum"},{"issue":"1","key":"12976_CR11","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1038\/s41415-022-4404-6","volume":"233","author":"J Virdee","year":"2022","unstructured":"Virdee J, Thakrar I, Shah R, Koshal S. Going electronic: an epic move. Br Dent J. 2022;233(1):55\u20138.","journal-title":"Br Dent J"},{"issue":"4","key":"12976_CR12","doi-asserted-by":"publisher","first-page":"252","DOI":"10.1097\/QMH.0b013e31826d1f28","volume":"21","author":"H Singh","year":"2012","unstructured":"Singh H, Khan R, Giardina TD, Paul LW, Daci K, Gould M, El-Serag H. Post-referral colonoscopy delays in diagnosis of colorectal cancer: a mixed-methods analysis. Qual Saf Health Care. 2012;21(4):252.","journal-title":"Qual Saf Health Care"},{"issue":"2","key":"12976_CR13","doi-asserted-by":"publisher","first-page":"375","DOI":"10.1038\/ajg.2016.555","volume":"112","author":"RB Issaka","year":"2017","unstructured":"Issaka RB, Singh MH, Oshima SM, Laleau VJ, Rachocki CD, Chen EH, Day LW, Sarkar U, Somsouk M. Inadequate utilization of diagnostic colonoscopy following abnormal FIT results in an integrated safety-net system. Am J Gastroenterol. 2017;112(2):375.","journal-title":"Am J Gastroenterol"},{"key":"12976_CR14","doi-asserted-by":"publisher","first-page":"e43024","DOI":"10.2196\/43024","volume":"9","author":"M Guo","year":"2023","unstructured":"Guo M, Brar Prayaga R, Levitz CE, Kuo ES, Ruiz E, Torres-Ozadali E, Escaron A. Tailoring a text messaging and Fotonovela program to increase patient engagement in colorectal Cancer screening in a large urban community clinic population: quality improvement project. 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Cancer. 2022;128(11):2119\u201325.","journal-title":"Cancer"},{"issue":"4","key":"12976_CR17","first-page":"53","volume":"2","author":"A Baus","year":"2020","unstructured":"Baus A, Wright LE, Kennedy-Rea S, Conn ME, Eason S, Boatman D, Pollard C, Calkins A, Gadde D. Leveraging electronic health records data for enhanced colorectal cancer screening efforts. J Appalach Health. 2020;2(4):53.","journal-title":"J Appalach Health"}],"container-title":["BMC Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-025-12976-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12913-025-12976-3","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-025-12976-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T11:14:33Z","timestamp":1781608473000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12913-025-12976-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,1]]},"references-count":17,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["12976"],"URL":"https:\/\/doi.org\/10.1186\/s12913-025-12976-3","relation":{},"ISSN":["1472-6963"],"issn-type":[{"value":"1472-6963","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,1]]},"assertion":[{"value":"28 March 2024","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"28 May 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"1 July 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This project was a quality improvement project as such no IRB approval was required. Per our Emory University School of Medicine IRB guidance \u201c\n                      \n                      \u201d. Our project aims to show successful local improvement in access to GI services, colorectal cancer screening rates, and providers screening colonoscopy referral request to procedure scheduling. We have attached a PDF to further clarify our institutional policy.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"N\/A.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"832"}}