Care Coordination and 360 Referrals (Proof of Concept) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Closed Loop Referral (360X)

IHE 360 Exchange Closed Loop Referral (360X) lets providers on different systems exchange a referral request and its result, from within their own workflow, "when the expectation is that the patient will eventually return to the referring provider for continued care" (PCC TF-1 X).

References

• IHE PCC 360X supplement (Rev. 1.2 Trial Implementation, 2021-04-14)
• NW GMSA - Genetic Referrals - the pattern applied to clinical genetics

Actors and Transactions

R = required, O = optional (PCC TF-1 Table X.1-1). [PCC-56] or [PCC-57] received by the Referral Initiator ends the referral. Receiving an optional transaction that is not supported must not be treated as an error.

Process Flow

The closed loop from referral to outcome. Dashed lines are optional steps.

flowchart LR
    subgraph RI [Referral Initiator]
        I1[Decide to refer] --> I2[Referral form<br/>optional]
        I2 --> I3[Create referral]
        I9[Review outcome<br/>close referral]
    end
    subgraph RR [Referral Recipient]
        R1[Triage] --> R2{Accept?}
        R2 -- No --> R3[Decline<br/>PCC-55 / PCC-56]
        R2 -- Yes --> R4[Appointment<br/>see below]
        R4 --> R5[Clinic attendance /<br/>episode of care]
        R5 -.-> R6[Interim Consultation Note<br/>PCC-59]
        R5 --> R7[Referral Outcome<br/>PCC-57]
    end
    I3 -- "Referral Request<br/>PCC-55" --> R1
    R3 --> I9
    R6 -.-> I9
    R7 --> I9

Referral forms may be used at either point: to create the referral (the initiator completes the form, which becomes ServiceRequest.supportingInfo), and / or before clinic attendance (below). See Referral Forms.

Appointment Booking

In England the appointment is booked by either side:

• Referral Initiator - when the referral is made, for example an eRS directly bookable service, with the patient choosing the slot.
• Referral Recipient - after triage, through eRS Referral Assessment Services or the trust PAS.

flowchart TD
    A[Create referral] --> B{Who books?}
    B -- "Referral Initiator<br/>(eRS)" --> C[Patient chooses slot<br/>when referring]
    B -- "Referral Recipient" --> D
    C --> D[Triage and accept]
    D --> E{Slot booked<br/>and suitable?}
    E -- "No - book or reschedule" --> F[Recipient books slot<br/>eRS RAS or trust PAS]
    E -- Yes --> G
    F --> G[Appointment Notification<br/>PCC-60]
    G -.-> H[Pre-attendance form<br/>optional]
    H -.-> I
    G --> I[Clinic attendance]
    I -. "did not attend" .-> J[No-Show Notification<br/>PCC-61]
    J -. rebook .-> F
    J -. "or decline" .-> K[Referral Decline<br/>PCC-56]

• When the initiator has booked, the Appointment Notification [PCC-60] confirms or reschedules the slot - the initiator's system already knows of the booking, so this may be a confirmation only.
• The pre-attendance form is requested by the recipient from the patient or the referrer, as a Referral Task input, and completed before the clinic.
• See Appointment [PCC-60] / No-Show [PCC-61] and NHS England Referral and Report Services.

State Transitions

360X defines the referral states from each actor's point of view (PCC TF-1 X.4.1). Combined, and coded in Referral Workflow Status:

stateDiagram-v2
    [*] --> requested: PCC-55 Referral Request
    requested --> accepted: PCC-55 Accept
    requested --> declined: PCC-55 Decline
    requested --> information_requested: more information needed (NHS)
    information_requested --> requested: information supplied
    requested --> redirected: redirected to another service (NHS)
    accepted --> deferred: on hold (NHS)
    deferred --> accepted: resumed
    deferred --> cancel_requested: PCC-58
    accepted --> appointment_booked: PCC-60
    appointment_booked --> no_show: PCC-61
    appointment_booked --> interim_report: PCC-59
    no_show --> appointment_booked: rebooked
    accepted --> interim_report: PCC-59
    interim_report --> interim_report: PCC-59
    accepted --> completed: PCC-57
    appointment_booked --> completed: PCC-57
    interim_report --> completed: PCC-57
    accepted --> declined: PCC-56 (e.g. after no-show)
    no_show --> declined: PCC-56
    requested --> cancel_requested: PCC-58
    accepted --> cancel_requested: PCC-58
    cancel_requested --> cancelled: PCC-58 Confirmation
    cancel_requested --> completed: PCC-57 (too late to cancel)
    declined --> [*]
    redirected --> [*]
    cancelled --> [*]
    completed --> [*]

Points that matter for implementers:

• A decline can arrive at any time, not only as the first response. The Referral Initiator must handle a "delayed" decline after an acceptance.
• A cancellation request may not be honoured. The Referral Recipient may reply with the next workflow step (for example a Referral Outcome) instead of a confirmation.
• After a decline a new referral needs a new Referral ID.
• information-requested is not in 360X. It is added for the eRS and BaRS "return to referrer" step.
• deferred and redirected are not in 360X and are provisional. They are based on the HL7 v2 order control codes for a held order (ORC-1 OH, ORC-5 HD) and a replaced order (ORC-1 RU, ORC-5 RP) and the FHIR Task on-hold state; the NHS processes behind them (deferral, eRS redirect) are To confirm. A deferred referral is on hold and resumes as accepted. A redirected referral ends; the referral to the other service is a new referral with a new Referral ID that replaces it (eRS keeps the UBRN). Who raises the new referral - the Referral Recipient (e.g. a Referral Assessment Service) or the Referral Initiator - is To confirm.
• Without the Scheduling Option the Referral Recipient can report a no-show as the reason for a Referral Decline [PCC-56].

Identifiers

360X requires two identifiers in every message, in both directions (PCC TF-1 X.1.3):

In England the NHS Number is the shared patient identifier. Where the referral was made through eRS, the UBRN is a second referral identifier known to both sides.

Options

360X's own message content is HL7 v2 (OMG^O19, OSU^O51, SIU), with a clinical document alongside. This guide keeps that split - a small workflow message and a document - and gives each a FHIR equivalent (ServiceRequest / Task and a FHIR Document).

Use Cases

GP to Specialist

360X Use Case #1 restated for the NHS (example resources in brackets):

1. Hodor TAMESIDE (an NW GMSA test patient; Mr Packton in 360X) sees Dr Allen, his GP, with shortness of breath. BMI 30, non-smoker, no chest pain, family history of coronary artery disease.
2. Dr Allen refers him to cardiology, asking "Determine the origin of Mr Tameside's shortness of breath", to be seen within a week. The referral carries the findings, history and results (Referral Request). In England this would usually go through eRS.
3. The cardiology service triages and accepts the referral (Accepted), or declines it with a reason (Declined).
4. The service books an appointment and notifies the GP (Appointment). Through eRS, the GP (with the patient) could instead have booked the slot when referring.
5. Dr Brown sees the patient, diagnoses coronary artery disease and books a cardiac catheterisation. The clinic letter answers the referral question (Interim clinic letter).
6. After the catheterisation Dr Brown sends a final letter with a plan of care and discharges the patient to the GP (Referral Outcome - HDR, Completed).
7. Dr Allen reviews the notes and closes the referral.

sequenceDiagram
    participant GP as Referral Initiator<br/>GP practice
    participant CAR as Referral Recipient<br/>Cardiology
    GP ->> CAR: Referral Request [PCC-55]
    CAR -->> GP: Referral Accept [PCC-55]
    CAR ->> GP: Appointment Notification [PCC-60]
    CAR -->> CAR: Clinic visit
    CAR ->> GP: Interim Consultation Note [PCC-59]
    CAR -->> CAR: Cardiac catheterisation
    CAR ->> GP: Referral Outcome [PCC-57]
    GP -->> GP: Close referral

Public Health to Specialist

360X Use Case #2 is newborn hearing screening: a public health programme (or the GP) refers a baby who did not pass screening to audiology, and the audiology result updates the hearing plan of care. The NHS equivalent is the NHS Newborn Hearing Screening Programme, whose national IT system is not covered here - Open. The pattern is the same, with a care plan as the outcome (see Dynamic Care Planning).

Virtual Ward

A GP or community team refers a patient to a virtual ward instead of an acute admission; the outcome is a discharge report. See Virtual Wards.

Secondary Referrals and End of Care

• 360X treats a specialist-to-specialist (secondary) referral as a new referral. The original Referral Initiator is told about it through an Interim Consultation Note or the Referral Outcome, usually as part of the plan of care.
• The loop is closed at End of Care. For referrals for continued care (for example long-term specialist follow-up) the loop can be closed by accepting the referral and sharing a care plan as the outcome.

Cross Profile Considerations