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J Am Med Inform Assoc. 2018 Jun 1;25(6):715-721. doi: 10.1093/jamia/ocy004.

Closing the loop with an enhanced referral management system.

Author information

Information Systems, Partners HealthCare, Somerville, MA, USA.
Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
Department of Medicine, Harvard Medical School, Boston, MA, USA.
Newton Wellesley Hospital, Newton, MA, USA.
NorthShore Physicians Group, Danvers, MA, USA.
Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA.



To evaluate the impact of a referral manager tool on primary care practices.

Materials and Methods:

We evaluated a referral manager module in a locally developed electronic health record (EHR) that was enhanced to improve the referral management process in primary care practices. Baseline (n = 61) and follow-up (n = 35) provider and staff surveys focused on the ease of performing various steps in the referral process, confidence in completing those steps, and user satisfaction. Additional metrics were calculated that focused on completed specialist visits, acknowledged notes, and patient communication.


Of 1341 referrals that were initiated during the course of the study, 76.8% were completed. All the steps of the referral process were easier to accomplish following implementation of the enhanced referral manager module in the EHR. Specifically, tracking the status of an in-network referral became much easier (+1.43 [3.91-2.48] on a 5-point scale, P < .0001). Although we found improvement in the ease of performing out-of-network referrals, there was a greater impact on in-network referrals.


Implementation of an electronic tool developed using user-centered design principles along with adequate staff to monitor and intervene when necessary made it easier for primary care practices to track referrals and to identify if a breakdown in the process occurred. This is especially important for high-priority referrals. Out-of-network referrals continue to present challenges, which may eventually be helped by improving interoperability among EHRs and scheduling systems.


An enhanced referral manager system can improve referral workflows, leading to enhanced efficiency and patient safety and reduced malpractice risk.


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