npsfCambridge, MA, November 29, 2017 — Patient referrals are getting a closer look because the process is not as thorough or efficient as it should be, say experts studying the matter, which can lead to delays in diagnosis and treatment and other lapses in patient safety. Today the Institute for Healthcare Improvement (IHI) released guidelines to help standardize the ways in which primary care practitioners activate referrals to specialists and then keep track of the information over time. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era is the work of an expert panel convened to examine current obstacles to a high-quality, safe referral process and offer improvement strategies for clinicians, organizations, and electronic health record (EHR) vendors to pursue.

The work was supported by a grant from CRICO/Risk Management Foundation of the Harvard Medical Institutions and initiated by the National Patient Safety Foundation (NPSF), which merged with IHI in May 2017.

Patient referrals are on the rise in the US, increasing from 40.6 million in 1999 to 105 million in 2009. Even with the advent of EHRs, steps are missed as clinicians and staff deal with an array of challenges such as work overload, ambiguity of roles, communication breakdowns, and variation in requirements among specialists. Patients also struggle to follow through on referrals when they are not sufficiently engaged in the process.

“In a perfect world, any patient who is referred by one clinician to another would be seen in a timely fashion, and communication between the clinicians and with the patient would be seamless,” says Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, IHI. “In reality, health professionals find current practices highly inefficient, and patients are caught in the middle, sometimes having no idea who’s ultimately responsible for the referral or the clinical findings that emerge as a result. Our goal was to come up with something far more reliable.”

The recommendations are designed to replace numerous defects in the system with processes that ensure significant collaboration among all stakeholders and easier access to referral information by all parties so that nothing important is forgotten or lost. This is accomplished through a “closed-loop” process in which all relevant patient information is communicated to the correct person through the appropriate channels and in a timely manner.

The expert panel identified nine steps in a closed-loop referral process, and potential pitfalls and solutions for each. They then looked at both technical (hardware and software) and sociological (workflow, staff) factors that influence the use of technology in health care. General recommendations are offered along with specific recommendations for each of the nine steps and for the various stakeholders – clinicians, practice leaders, and EHR vendors.

“In the ambulatory setting, our data analysis reveals almost half of the malpractice claims from our members involve some kind of failure to follow up,” says Luke Sato, MD, Senior Vice President and Chief Medical Officer, CRICO. “Many of the recommendations of this work are feasible with existing technology and enable a system for closing the loop on referrals. Our intention is to achieve this without adding to the administrative burden of clinicians.”

The multidisciplinary expert panel was led by co-chairs Hardeep Singh, MD, MPH, Chief of the Health Policy, Quality, and Informatics Program at Houston Veterans Affairs Health Services Research Center for Innovations, and David Y. Ting, MD, FACP, FAAP, Chief Medical Information Officer, Massachusetts General Physicians Organization, and included clinicians, researchers, patients, and industry representatives.

Members of the expert panel will present an overview of the guidelines during an open webinar on January 10, 2018. Visit the web page for details. This resource is available on the IHI website.

The Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) began working together as one organization in May 2017. The newly formed entity is committed to using its combined knowledge and resources to focus and energize the patient safety agenda in order to build systems of safety across the continuum of care. Visit

For more than 40 years, CRICO has served the clinicians, institutions, and employees of the Harvard medical community with a superior medical professional liability program, and an extensive array of patient safety resources. The strength of our program comes from the delivery of strong insurance protection and claims management through vigorous yet fair malpractice defense strategies. CRICO works closely with organizational leaders and physicians to provide insured-clinicians the support they need in the aftermath of an adverse event.

Related Article

Toward an Ideal Referral Process

Press Releases from CRICO

See CRICO press releases
Cookies help us improve your website experience.
By using our website, you agree to our use of cookies.