Identifying and Mitigating Patient Safety Risks Associated With Telehealth Referrals

The Doctors Company Foundation supports the development of an assessment tool to help healthcare systems identify and mitigate patient safety risks associated with referrals from telehealth to in-person care.

Grantee Profile

The MedStar Health National Center for Human Factors in Healthcare is one of the largest human factors programs embedded within a U.S. healthcare system. Through applied research, usability, safety advisement, and education, the MedStar Health National Center for Human Factors in Healthcare is dedicated to the scientific study of how humans think, work, and interact within the healthcare environment.

“Our team would like to express our gratitude and appreciation for your support of this important work! We look forward to applying for future federal and foundation funding opportunities that will allow us to build on this work in order to develop more actionable solutions to improve the safety of referrals from telehealth to in-person care, ensuring that patients who are referred to in-person care can access the care that they require.”
Kylie M. Gomes, PhD, Project Lead, Research Scientist, National Center for Human Factors in Healthcare, MedStar Health Research Institute, and Assistant Professor, Georgetown University School of Medicine­

The Challenge

The COVID-19 pandemic rapidly accelerated the adoption and use of on-demand telehealth (i.e., unscheduled telehealth visits). In the years following the initial peak pandemic phases, the adoption of on-demand telehealth has continued to increase.

Despite the benefits of telehealth, such as improving access to care, it is likely that unintended consequences and safety risks are also associated with delivering care remotely because patients and providers interact through a new and unfamiliar modality. A subset of patients seen through on-demand telehealth will inevitably require referral to in-person care, raising concerns about whether patients who are referred from telehealth to in-person care will successfully follow through on referrals.


  • Our goal is to provide a comprehensive understanding of risks inherent in the on-demand telehealth referral and develop a rigorous assessment tool to help facilities mitigate risks during the referral process.
  • The project aims to pinpoint the factors that adversely affect the appropriate and successful referral from telehealth to in-person care.
  • Research activities have included developing an institutional review board protocol, developing interview guides, conducting patient interviews, analyzing data, and working with subject matter experts who contributed additional human factors expertise and support for the team’s activities.

Goals Achieved

Our interviews with patients and providers helped identify and elucidate specific risks associated with the on-demand telehealth referral process.

The team translated the findings from the interviews and the feedback from our subject matter experts into needs statements for a safe and effective telehealth referral process.

From these results, we developed a guide that highlights these specific risks and provides examples of how these risks can impact patient safety and a risk assessment tool that can be used by healthcare systems to evaluate their telehealth referral process and identify areas for improvement.

Assessment/Takeaways/Next Steps

We found that providers are concerned about a number of risks associated with the telehealth referral process. Their concerns include a lack of clear guidelines on when to refer a patient to in-person care, variability between providers in the information shared with patients about how to follow up, and the need for additional clinical support to determine if a referral to in-person care is needed and whether support is available during the telehealth visit.

Patients mentioned several barriers that may have an impact on their ability to follow up on referrals from telehealth to in-person care. Difficulties include a lack of transportation, a lack of childcare/eldercare, the time commitment needed to access care due to long wait times and/or travel times, financial barriers, and an individual’s preference for telehealth in resolving all care needs.

Additionally, patients stated that they are less likely to seek in-person care when a provider does not convey the reasons for the referral or the level of urgency for seeking the recommended in-person care.

The next steps of the project include identifying and developing solutions to support safe and effective referrals from on-demand telehealth to in-person care and ensuring that patients successfully access and follow through on referrals.

For Further Information