Empowering Emergency Departments with AI: Introducing the Reason for Transfer Model

Emergency departments (EDs) are the heartbeat of acute care—but they’re under increasing strain. Staffing shortages, rising patient volumes, and complex cases are stretching clinicians thin. In these high-pressure environments, access to timely, relevant patient data can make the difference between a smooth transition and a missed opportunity for intervention.

At PointClickCare, we’re committed to transforming emergency care through real-time, actionable insights. Our latest innovation—the Reason for Transfer AI Model—is designed to support ED teams with the context they need to make faster, more informed decisions for patients arriving from post-acute care settings.

Data Gaps Undermine Emergency Care for the Most Vulnerable

Emergency departments are facing growing complexity—not just from rising patient acuity and volume, but also from gaps in patient history. One of the most persistent challenges? Patients arriving from post-acute care settings, often without the context needed to guide rapid clinical decisions. When a skilled nursing facility (SNF) sends a patient to the ED, the focus is on getting them there safely, not necessarily on providing a complete clinical picture. At best, ED staff may receive a packet of notes—sometimes pinned to the patient, sometimes lost in transit. And even when documentation does arrive, it’s often described as “a ream of paper”—too much to process in the moment, with little time to find what matters. The EMS team may know little more. It leaves clinicians filling in the blanks, often without a clear understanding of what prompted the transfer in the first place.

Unfortunately, that lack of clarity isn’t the exception—it’s the norm, and the stakes are high. One-third of patients discharged from hospitals to SNFs are sent back to the ED within 30 days, contributing to more than $52.4 billion in avoidable costs.¹ This lack of interoperability and actionable insights that are critical at the point of care, can delay treatment, increase readmissions, and compromise outcomes — especially for vulnerable populations. As patients increasingly face longer ED stays, the need for streamlined, contextual data becomes even more urgent to avoid delays in care and improve patient outcomes.

Introducing Data-Driven Context and Insights Powered by AI

PointClickCare is uniquely positioned to support emergency clinicians in understanding why a patient from post-acute care has arrived in their ED—because we have access to real-time, post-acute data that no other organization can offer. With the largest connected senior care network in the U.S., we deliver timely insights across the post-acute ecosystem that help ED teams see what others can’t: the care context behind the transfer.

To bring this data to the bedside, we developed the Reason for Transfer AI Model, now integrated within our ED solution. The model uses natural language processing to extract and summarize key clinical insights from SNF EHR notes — specifically those from the 24 hours preceding a transfer.

Upon arrival at the ED, clinicians receive a concise, context-rich summary highlighting key insights from the 24 hours leading up to the transfer. These may include changes in condition such as falls, adverse medication reactions, abnormal vital signs, signs of stroke, or other clinically significant events. The insights are delivered in a “pushed” format, meaning they arrive proactively; no searching required. The full source notes remain accessible for deeper review, but the summary enables faster triage and more confident decision-making from the start. This model isn’t meant to replace clinical judgment; it’s designed to strengthen it. By surfacing timely, targeted insights at the moment of decision, it helps care teams act faster, coordinate more effectively, and improve continuity of care — whether that means stabilizing, admitting, or safely returning the patient to their SNF to complete their care.

Why Responsible AI Matters—and How PointClickCare Leads

AI is transforming healthcare—but not all AI is created equal. At PointClickCare, our approach to AI is grounded in trust, transparency, and collaboration. We believe that responsible AI isn’t just a technical standard but a clinical imperative.

Our models are built responsibly, in partnership with industry leaders like Microsoft and the Coalition for Health AI (CHAI). These collaborations ensure that our solutions meet rigorous ethical and regulatory standards, while remaining focused on real-world clinical impact.

We also test our models rigorously. Our R&D teams include PhD scientists, regulatory experts, and practicing clinicians who work together to validate each model against real-world scenarios. This ensures that our AI is not only accurate, but also usable and safe in high-stakes environments like the ED.

Finally, our AI is embedded directly into the workflow. We don’t ask clinicians to adopt new tools or platforms—we deliver insights where they’re already working. This seamless integration is key to adoption and impact, especially in emergency settings where time and attention are limited.

Transforming Emergency Care, Responsibly

The Reason for Transfer AI Model represents a significant step forward in emergency care. By delivering real-time, actionable insights before the clinician reaches the bedside, we’re helping ED teams make faster, more informed decisions—ultimately improving outcomes for some of the most vulnerable patients. At PointClickCare, we’re proud to lead the way in responsible, impactful AI innovation that meets clinicians where they are and supports them in delivering the best possible care.