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Closing the Referral Loop

Improving Ambulatory Referral Management, Electronic Health Record Connectivity, and Care Coordination Processes

Davidow, Stephen L., MBA-HCM, CPHQ, APR; Sheth, Jignesh, MD, MPH; Sixta, Constance S., PhD, MBA, RN; Thomas-Hemak, Linda, MD

The Journal of Ambulatory Care Management: October/December 2018 - Volume 41 - Issue 4 - p 240–249
doi: 10.1097/JAC.0000000000000247
Original Articles

More than 105 million referrals of Medicare beneficiaries to specialists occur annually. Different settings and electronic health records have made care coordination complex. PCPI (formerly American Medical Association-convened Physicians Consortium for Performance Improvement) and The Wright Center for Graduate Medical Education sponsored the Closing the Referral Loop pilot project. Twelve dyads of primary care and specialist physicians sought to improve ambulatory referrals by mapping the referral process, and using care compacts, metrics, and electronic health records. Referrals closed on time increased from 40% to 70%. Clinical questions answered increased from 50% to 75%. Adoption of the change package and lessons from this project may significantly improve ambulatory referral management.

PCPI, Chicago, Illinois (Mr Davidow); and The Wright Center for Graduate Medical Education, Scranton, Pennsylvania (Drs Sheth, Sixta, and Thomas-Hemak).

Correspondence: Stephen L. Davidow, MBA-HCM, CPHQ, APR, Director, Quality Improvement, PCPI, 330 N. Wabash Ave, Ste 39300, AMA Plaza, Chicago, IL 60611 (;

The authors wish to recognize the significant contributions of Dana Richardson, MHA, RN, who served as Director of PCPI Operations and Strategic Initiatives at the American Medical Association, for her early leadership and support of the Closing the Referral Loop project; and Courtney Dempsey, BS, Clinical Innovation Specialist, The Wright Center for Graduate Medical Education, who served as the liaison with the participating clinicians and their teams.

The CRL pilot project was funded by PCPI through a payment to TWC to support meetings and other logistics. TWC funded the improvement advisor. Both organizations provided staff expertise and management throughout the project. Dyad sites were not reimbursed for their participation.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

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