This article is part of our Expert Insights series, where experienced healthcare IT consultants share practical perspectives from real engagements.
Nicole Guevara, MD is a clinical informaticist and EHR consultant specializing in ambulatory workflow optimization, athenaOne, eClinicalWorks, and Elation Health. She partners with HealthTECH Resources to help medical groups, FQHCs, and multisite practices get more from their EHR platforms.
A few years ago, I worked with a large multispecialty medical group that believed they had a referral problem.
Their leadership team kept asking the same question: “Why are so many patients never making it to the specialist?”
At first glance, the numbers were alarming. Thousands of referrals were being generated, yet only a fraction ever resulted in completed specialty appointments.
The instinct was to launch a referral management program immediately.
Instead, I recommended something different: don’t build a solution until you’ve audited the process.
That recommendation changed everything.
What We Found
Once we mapped the end-to-end workflow inside athenaOne, it became obvious that referral leakage wasn’t caused by one broken step. It was death by a thousand small operational gaps.
- Some referrals never left the ordering provider’s inbox.
- Others were missing required information.
- Many reached the patient, but no one owned the next step.
Patients were handed a referral and told, “Call us when you’re ready.” Many never did.
This wasn’t a technology problem. It was an ownership problem.
The existing workflow relied heavily on patients initiating the scheduling process after leaving primary care. In the pilot data, only about 30% of internal referrals ultimately resulted in completed specialty appointments. The redesigned referral-to-appointment workflow shifted scheduling to the point of checkout and aligned primary care and specialty teams around shared ownership of the referral process.
Before Building a Referral Program, Audit These Areas
Too many organizations jump straight into dashboards and work queues. I always start with an operational audit. Here are the questions I ask.
1. Where is the referral actually getting stuck?
Break the process into stages:
- Referral ordered
- Referral signed
- Referral transmitted
- Patient contacted
- Appointment scheduled
- Appointment completed
If you can’t identify where referrals are dropping, you can’t fix the problem.
2. Who owns each step?
One of the biggest findings was that everyone believed someone else was responsible.
- Primary care assumed scheduling would happen later.
- The call center assumed the clinic had already contacted the patient.
- Specialty staff assumed patients would call.
No one owned the referral from beginning to end.
3. Is athenaOne configured to support the workflow?
Technology should reinforce the process. Review items like:
- Referral order configuration
- Referral tracking
- Patient Cases
- Work queues
- Scheduling templates
- Status definitions
- Reporting fields
Poor configuration often creates invisible work that never appears on reports.
4. What happens after the patient leaves?
This is where most referral programs fail. If the patient doesn’t schedule before leaving the clinic:
- Who follows up?
- How many outreach attempts occur?
- How quickly?
- Where is that documented?
- When is the referral considered closed?
The referral-to-appointment workflow intentionally moved referral scheduling as close to checkout as possible, then used Patient Cases so the specialty team could verify appointments, make corrections when needed, and maintain continuity of care.
The Data Told a Different Story
As the engagement progressed, another question surfaced from leadership: “Can’t athenaOne already report on referral leakage?”
The answer was yes, but only to a point.
athenaOne already offered referral reporting and operational data. The challenge wasn’t a lack of information. The challenge was turning that information into actionable insights.
We discovered that referral statuses weren’t always updated consistently. Some referrals remained open long after patients had already been seen. Appointments weren’t always linked back to the originating referral. Different departments documented referral activity differently.
Leadership had reports. What they didn’t have was confidence in the data.
Rather than accepting the standard reports at face value, my colleagues and I first completed a comprehensive workflow audit. We wanted to understand exactly how referrals moved through the organization before attempting to measure performance.
Once the workflow was standardized, we leveraged athenaOne as the source system and developed executive dashboards in Domo that transformed operational data into meaningful business intelligence.
Instead of simply counting referrals, leadership could finally answer operational questions such as:
- Where are referrals leaking?
- Which specialties have the highest referral conversion rates?
- Which clinics require additional operational support?
- How long does it take patients to schedule after a referral is ordered?
- Which providers generate the highest percentage of incomplete referrals?
- Where are the biggest bottlenecks across the referral lifecycle?
The dashboards themselves didn’t solve the problem. They made the problem visible. And once everyone, from frontline staff to executive leadership, could see the same operational story, improvement became measurable.
One of the biggest lessons from the project was this: clean workflows produce clean data. Clean data produces better decisions.
The Result
After auditing the workflow, we didn’t simply implement a referral management program. We redesigned the entire referral journey.
- Scheduling moved earlier in the patient experience.
- Primary care and specialty teams shared ownership.
- Follow-up became standardized.
- Referral status became visible.
- Leadership finally had meaningful operational metrics.
Most importantly, patients spent less time waiting for specialty care.
During the pilot, referral-to-appointment conversion improved from roughly a 31% baseline to approximately 43%, generating dozens of additional booked referrals while establishing a standardized, end-to-end ownership model.
Where I Help
One of the most common mistakes I see is organizations assuming they need another referral coordinator, another dashboard, or another software solution. More often than not, they already have the tools they need inside athenaOne. What they need is a better workflow.
Before recommending technology changes or additional staffing, I perform a comprehensive Referral Management Audit to identify where referrals are leaking, why they’re leaking, and how athenaOne can be optimized to support a more efficient, patient-centered process.
- Workflow Assessment
- athenaOne Configuration Review
- Communication and Handoff Optimization
- Referral Leakage Analytics and Business Intelligence
- Process Standardization and Staff Adoption
After years of optimizing ambulatory operations, I’ve learned one thing: referral leakage is rarely a referral problem. It’s almost always a workflow problem hiding inside the EHR.
A well-configured athenaOne should make the right process the easiest process. When organizations combine standardized workflows, thoughtful athenaOne optimization, clear ownership, and meaningful business intelligence, they reduce referral leakage, improve patient access, strengthen care coordination, and create a better experience for both patients and staff.
Before investing in another referral coordinator, another dashboard, or another software solution, audit the process first. The biggest opportunity is often already sitting inside your athenaOne; you just haven’t optimized it yet.
If your referral-to-appointment numbers don’t look right, or you’re not sure where referrals are dropping, I can help you find out.