Tech-driven ED Referral Tightens Care Coordination

Emergency departments (EDs) across the United States are facing increasing strain as patient visits reached nearly 140 million in 2024.

These rising volumes compound long‑standing challenges such as overcrowding, staffing shortages and extended wait times. These constraints disrupt clinical workflows and can negatively impact a patient’s experience.

One ongoing challenge is the referral of stable patients from outpatient settings to the ED.

“Routing stable patients to the ED through phone calls and limited documentation can lead to significant communication gaps and potential care delays,” says Jeffrey Ruwe, MD, Cleveland Clinic emergency medicine physician and Clinical Informatics and Throughput Medical Director.

He adds that providers are often pulled away from patient care to take calls, while ambulatory teams search for essential demographic or clinical information.

Closing the communication gap

Recognizing the need for better coordination, Dr. Ruwe partnered with ITD teams to develop a tech‑driven solution that embeds referral communication directly into the electronic health record (EHR). This approach gave ED teams critical information before a patient’s arrival.

“This digital solution improved the workflow by expediting triage and allowing ED teams to review essential information prior to the patient’s arrival,” says Drew Mastrangelo, Cleveland Clinic ITD lead systems analyst.

Initial efforts began in 2018 with a workflow designed to capture important referral information directly into the patient charts.

Mastrangelo explains, “Our first step was building a workflow that ensured critical information was documented directly in the patient chart.”

This integrated workflow gave triage nurses and physicians immediate access to actionable details, helping to expedite care, reduce ED length of stay and improve patient outcomes.

New order connects care teams

Building on this foundation led to the creation of the Ambulatory ED Expected Arrival Order, an enhanced EHR‑embedded workflow that enables ambulatory providers to place an order directly in a patient’s chart, detailing clinical concerns in advance so ED teams can prepare.

“The goal was to improve transitions of care with a warm handoff from outpatient settings to the emergency department that clearly communicated concerns and the care plan in a standardized way,” says Dr. Ruwe.

Providers defined the critical pre‑arrival details as referral reason, preferred ED destination, anticipated admission needs and contact preferences. From there, IT embedded those elements into a structured, easy‑to‑use format within the EHR.

As Mastrangelo explains, “The tools already existed within the system. It was about bringing the right teams together and connecting those pieces in a way that hadn’t been done before.”

Improving the ED handoff

With the new tool, an alert is triggered during triage when a referred patient arrives in the ED that immediately indicates who referred the patient, why they were sent and how to contact the referring provider.

“This alert provides essential details right away and remains visible as the patient moves to a room,” Dr. Ruwe explains. “By delivering this information upfront, the system reduces guesswork and improves communication between teams.”

Historically, many patients arrived without a completed note or a clear understanding of why they were referred.

“ED teams were left guessing and making calls to offices without knowing who to reach,” says Dr. Ruwe. “With the new order, providers can specify their contact preferences to ensure a better handoff.”

Early adoption, impact

The new workflow gained rapid adoption with more than 300 orders in its first two weeks.

“Even with limited data, early trends show referred patients are admitted at higher rates than walk‑ins,” says Dr. Ruwe. “This valuable information helps us predict patient needs while optimizing ED and inpatient capacity.”

The team uses the data to guide bed planning, patient routing and opportunities to redirect appropriate patients to urgent care or create direct admission pathways, particularly for high‑admission specialties such as oncology. Integration with external providers further strengthens continuity of care.

Looking ahead

The success of the Ambulatory ED Expected Arrival Order reflects close collaboration across inpatient, ambulatory and operational teams. Future enhancements will focus on predictive analytics, optimized routing and broader integration across access points.

“One of the biggest benefits is the data,” says Mastrangelo. “It allows us to see how patients move through the system and where changes in workflows or prioritization may be needed,” says Mastrangelo.

Dr. Ruwe adds, “There are opportunities to expand this well beyond its current use, especially as we integrate it with virtual care and other access points to the emergency department.”

Above all, Dr. Ruwe says, “This is about functioning as one Cleveland Clinic. No matter where patients enter the system, care teams are aligned, informed and ready, creating clarity and confidence when it matters most.”