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Closing the Referral Loop: How Better Technology Can Lead to a More Perfect World

Tejal K. Gandhi, MD, the Chief Clinical and Safety Officer at the Institute for Healthcare Improvement, recently said that, “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.”

This perfect world that Dr. Gandhi describes is the world of closed referral loops, marked by completed appointments and timely exchanges of documentation.

While perfection sounds simple enough, Dr. Gandhi continues her statement by pointing out what many of us who have worked in healthcare already know:

“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.”

Despite this unfortunate and common reality, we in the industry continue to struggle with finding a consistent way forward. If we want to make progress towards Dr. Gandhi’s vision of the perfect world, we need to find a solution to closing the referral loop, and before we do that, we need to understand the complexity of the situation.

The Struggle to Close the Referral Loop

A new study on primary care referrals helps illustrate the health industry’s struggle to close the referral loop.

Published by Malhar Patel, BSPH and his colleagues at Duke in 2018, the study reveals that out of 103,737 analyzed referral attempts, only 35% resulted in a closed referral loop, and in this narrow network, almost 20% of patient referrals were made to out-of-network providers.

In addition, none of the 19,288 referrals sent to an out-of-network specialist resulted in a closed referral loop, and a whopping 35% of the scheduled referral appointments eventually resulted in cancellations or patient no-shows.

Contributing factors to these findings include poorly documented appointment scheduling rates, wide variability between individual clinics, and patient access issues such as long wait times for appointments and geographic proximity.

Though their study focused on just one large academic health system with the majority of providers using the same EMR, the authors predicted that the highlighted problems are common amongst all health systems. My experience has shown me that systems with more complex provider networks and inconsistent referral management processes often face additional obstacles to closing the referral loop, especially for organizations whose networks are made up of provider groups on differing EMR systems. Without the benefit of interoperability between those disparate systems, closing the referral loop can only be enabled through time-consuming manual processes.

Added Pressures

While the clinical consequences of failing to close the referral loop are readily apparent, there are also regulatory and financial pressures that affect organizations that fail to close the referral loop.

“One thing is for sure: leakage of referrals to out of network specialists and other competitor services hurts any system’s bottom line.”

Regulatory concerns relating to referrals are increasing as CMS has included closing the referral loop as a required quality measure and promoting interoperability component in the Merit-based Incentive Payment Systems (MIPS) program. Provider and patient satisfaction with the referral process are also important considerations, but in most organizations, the primary care and specialty care groups often operate in silos with little real integration beyond the patient as the intermediary. This leads to inefficient and uncoordinated care and high rates of dissatisfaction amongst PCPs, specialists, and patients.

Referral management is also a primary financial concern for every health system - whether they are in a fee for service model where much of their revenue is driven by the volume of referrals to their in-network specialists or they are in a value-based reimbursement model attempting to prioritize population health outcomes and cost savings. Either way, one thing is for sure: leakage of referrals to out of network specialists and other competitor services hurts any system’s bottom line.

What stands in the way?

Providers face many challenges when it comes to closing the referral loop, but one of the most prevalent ones is that health system provider networks are often delivered via dozens of different EMR systems. At Blockit, we have worked with health systems that have gone through mergers and practice acquisitions which resulted in their in-network providers using more than 50 different EMR solutions. You can imagine the degree of interoperability needed to enable so many disparate EMR systems to communicate with each other.

Further complicating the challenge is the necessity of dual, bi-directional interfaces between the different EMR systems in order to close the referral loop. Frankly, the current solution to use outdated technology such as fax machines, landline phone triads, and patient call centers as the standard in processing referrals creates a tremendous administrative burden on staff and leads to clinically important time gaps in patient care.

This lack of truly integrated technology, along with the associated operational inefficiencies makes it extremely difficult for providers and their staffs to move past the workflow issues and see the benefit of an improved referral management strategy. Because many physician practices in these networks are separate businesses with their own administrative infrastructure, the difficulty for health system leaders to drive adoption of well-integrated referral management solutions becomes even more challenging.

How Innovation Can Help Close the Referral Loop

Thankfully, solutions do exist. Recent breakthroughs in EMR interoperability provide an opportunity for health systems to significantly improve the referral process and close the referral loop regardless of how many disparate EMRs are employed.

“Recent breakthroughs in EMR interoperability provide an opportunity for health systems to significantly improve the referral process and close the referral loop”

The authors from Duke noted that, “for out-of-network referrals, improved EMR interoperability is needed to track referral outcomes. Along with various Health Systems, Blockit and other healthtech companies have invested in referral tracking systems, with initial results of increased revenue, reduced referral leakage, and reduced cost. Reducing the data gap in EMR-generated reports is vital to accurately measure closing the referral loop.”

Better technology can track and report important referral metrics such as appointment follow-through and in-network vs. out-of-network referrals rates. New interoperability technology even allows specialists and PCPs using a different EMR to electronically exchange vital clinical documentation to improve care coordination and significantly increase the percentage of closed referral loops.

Paving a Path to a More Perfect World

Great technology can help solve the referral problem, but just because someone builds a better gadget doesn't necessarily mean that it can be simply “turned on” and solve a complex technical and operational problem. The organization’s leadership also needs to get involved.

The authors of the Duke study agree, stating that solving the referral problem “requires health systems to first develop data analysis infrastructure to measure rates of closing the referral loop, then develop processes to improve.”

It is important to understand that every health system has its own unique ecosystem and challenges, especially when it comes to managing their referral networks. First, the issues such as the ones detailed in the Duke study need to be identified, and there has to be a broad consensus that these are problems that need solving. System leadership will then need to engage all the stakeholders in the referral process and do an operational deep-dive to determine the best way to leverage the new and innovative solutions that exist.

At the end of the day, health systems will continue to merge, partner, acquire and grow. Value-based care will continue its path toward being the preferred payment model in health care. CMS will continue its regulatory efforts to promote clinical quality and interoperability both in general and specifically around patient referrals. Arriving at the perfect world will take the whole village and successful change doesn’t happen overnight. The great news is that the problems can be solved, and in many ways, it is already being solved. While it may take some time to arrive at a fully functional closed-loop process, thanks to new innovation in EMR interoperability we can start paving the way to a more perfect world.


Dave Gregorio is the Chief Customer Officer at Blockit and the author of the Purpose Quotient®, a nationally recognized framework for Organizational Development. A 30 year healthcare industry professional with a passion for people, Dave is the founder of the Heroes to Healthcare mission and CEO of ImPowerQ Associates LLC.


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