Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era

​Institute for Healthcare Improvement / National Patient Safety Foundation. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Cambridge, MA: Institute for Healthcare Improvement; 2017. (Available at ihi.org) 

Specialty referrals — when a clinician refers a patient to a specialist for evaluation or treatment — are on the rise in the US, increasing from 40.6 million in 1999 to 105 million in 2009. Yet, despite the advent of electronic health records (EHRs), the referral process is often hindered by ambiguity of roles, communication breakdowns, clinicians' workloads, and variations in requirements among specialists. Such difficulties can lead to missed or delayed diagnoses, delays in treatment, and other lapses in patient safety. 

The recommendations outlined in this publication are designed to help standardize the ways in which primary care practitioners activate referrals to specialists, and then keep track of the information over time.  

This publication describes a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels and in a timely manner. As the process involves significant collaboration among all stakeholders, the publication includes both general recommendations as well as recommendations specific to each step in the process and each stakeholder group. 

This work was supported by a grant from CRICO/Risk Management Foundation of the Harvard Medical Institutions.

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Additional Information

• Endorsements from numerous organizations for Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era
• The American College of Physicians provides resources to assist clinicians with referral management: ACP High Value Care Coordination Project