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Default Options to Increase Referrals to Cardiac Rehabilitation

Default Options to Increase Referrals to Cardiac Rehabilitation

Project status



Penn Medicine Heart and Vascular Center 

Neel Chokshi, MD, MBA 

Daniel Kolansky, MD 

Innovation leads


National Heart, Lung, and Blood Institute 


Cardiac rehabilitation (CR) has been demonstrated to reduce mortality, morbidity, and readmissions in cardiovascular patients. However, most eligible patients in the United States do not participate in CR, let alone complete the recommended number of sessions.  

Health systems often struggle to effectively refer eligible patients, contributing to low participation rates. At Penn Medicine, we found that cardiologists had to manually identify eligible patients during busy inpatient rounds and opt-in to refer them to CR. 


We partnered with the Penn Medicine Heart and Vascular Center to redesign the referral process from opt-in to opt-out.   

The new process leverages the electronic health record (EHR) to automatically identify patients who qualify for CR. When eligible patients are identified, the clinical team is automatically notified via text message, and a referral – complete with a list of nearby CR facilities – is created for a cardiologist to sign during rounds.   


At the start of 2016, the year before the intervention began, CR referral rates among the clinical sites that implemented the opt-out system hovered around 15 percent. By the end of 2018, rates had steadily increased to more than 85 percent. And compared to control sites, there was a 47 percentage point difference. 

Based on these results, the opt-out referral system has been implemented as the standard of care at the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center.