Care Coordination and 360 Referrals (Proof of Concept)
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Clinical Process

A referral is one step in a clinical process. This page places the closed loop referral in that process, aligned with the nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation).

References

The Process

flowchart LR
    S([Start<br/>patient administration]) --> A[Assessment]
    A --> D[Diagnosis]
    D --> P[Plan]
    P --> I[Implement]
    I --> E[Evaluate]
    E -->|further encounters| A
    E --> X([End<br/>patient administration])
    T[Diagnostic testing<br/>LTW, RAD] --> D
    A -.orders.-> T
    I -.referral.-> R[Referral Recipient]
    R -.outcome.-> E
    classDef ref fill:#D5E8D4;
    class I,R,E ref
Phase What happens Workflow FHIR resources
Start Register the patient, start an encounter or episode IHE PAM, HL7 v2 ADT; PDS Patient, Encounter
Assessment Observations, questionnaires, clinical decision support; order tests IHE LTW (NW GMSA), IHE SWF.b (Imaging) Observation, QuestionnaireResponse, ServiceRequest, DiagnosticReport
Diagnosis Record the problem or diagnosis - Condition
Plan Agree the care or treatment plan IHE DCP (Dynamic Care Planning) CarePlan, Goal, CareTeam
Implement Carry out the plan: referrals, prescriptions, tasks IHE 360X (this guide), eRS, BaRS, EPS ServiceRequest, Task, MedicationRequest
Evaluate Review the results that come back: referral outcome, consultation notes, discharge reports IHE 360X, Transfer of Care, HDR, QEDm, MHD Composition (document), DocumentReference
End Discharge, close the episode IHE PAM, HL7 v2 ADT A03 Encounter

The referral is the Implement step and its outcome feeds Evaluate. Without the outcome the referrer cannot evaluate, which is why the loop has to be closed.

Encounters

Each phase happens in one or more encounters. Inside an encounter the clinician follows SOAP:

SOAP Clinician Referral relevance
Subjective Views the record (EPR, shared care record, Health Data API) and talks to the patient Referral Recipient reads the referral and its clinical information
Objective Records observations Results for the consultation note
Assessment Records conditions Answer to the referral question
Plan Creates tasks, orders, referrals, prescriptions Onward (secondary) referral, plan of care in the outcome

The end of an encounter is itself a reporting event: an outpatient letter, an emergency department attendance summary or a discharge summary (see Referral Outcome Reports).

Where This Guide Fits

Clinical step Order and report pattern This guide
Order a laboratory test LAB-1 / LAB-3 NW GMSA LTW, Cancer Pathology Report
Order an imaging examination RAD-2 / RAD-128 Enterprise Imaging
Refer for advice, assessment or treatment PCC-55 / PCC-57 Closed Loop Referral (360X)
Refer to a virtual ward PCC-55 / PCC-57, with a care plan Virtual Wards
Prescribe PHARM-5 / PHARM-8 (IHE MPD); EPS prescription / dispense notification NHS England - EPS
Coordinate care across a care team Shared CarePlan and Task Dynamic Care Planning