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

Clinical Referral Domain Model

The referral itself - the request sent by the Referral Initiator in Referral Request [PCC-55] - as a domain model with ServiceRequest as the main entity. It covers only what the referrer sends: the patient, where the referral was made, who refers, who is asked, what for and why, and the supporting information. The workflow that follows is not part of this model:

The same shape is used for diagnostic orders: the NW GMSA Genomic Test Order is a ServiceRequest with the patient, hospital spell, requester and reason, plus a specimen. A referral is that order without the specimen and with richer supporting information.

This page follows the Clinical Referral logical model and its breakdown into an implementation model: it covers the bulk of that model - the request - in detail.

References

• FHIR ServiceRequest and FHIR Workflow
• IHE PCC 360X - Referral Request [PCC-55], OMG^O19
• NW GMSA - Genomic Test Order and NW GMSA HL7 v2 conventions
• PRSB Clinical Referral Information Standard v1.0 - clinical headings

Domain Archetype

The entities a referral carries, with ServiceRequest at the centre:

erDiagram
    Patient ||--|{ ServiceRequest : subject
    Encounter ||--o{ ServiceRequest : encounter
    ServiceRequest }o--|| PractitionerRole : requester
    PractitionerRole }o--|| Organization : organization
    ServiceRequest }o--o{ HealthcareService : performer
    ServiceRequest }o--o{ Condition : reasonReference
    ServiceRequest ||--o{ SupportingInformation : supportingInfo
    ServiceRequest }o--o| CarePlan : basedOn

    Patient {
        Identifier nhsNumber
        Identifier medicalRecordNumber
        date birthDate
        string postalCode
        Reference generalPractitioner "GP practice (ODS)"
    }
    Encounter {
        Identifier visitNumber "VN - attendance"
        Identifier spellIdentifier "AN - admission"
    }
    ServiceRequest {
        Identifier referralId "Placer - Referral ID"
        Identifier ubrn "eRS"
        code status
        code intent "order"
        CodeableConcept category "referral"
        CodeableConcept code "Service referred to"
        code priority
        dateTime occurrence "Expected by"
        CodeableConcept reasonCode
        dateTime authoredOn
        Annotation note "Referral question"
    }
    PractitionerRole {
        Identifier practitionerIdentifier "Referrer (GMC / GMP)"
    }
    Organization {
        Identifier organisationCode "Referring organisation (ODS)"
    }
    HealthcareService {
        Identifier serviceIdentifier "eRS / DoS service"
    }
    Condition {
        CodeableConcept code "Reason for referral"
    }
    SupportingInformation {
        Reference document "HDR / EPS / letter"
        Reference questionnaireResponse "Referral form"
        Reference observation "Findings"
    }
    CarePlan {
        CodeableConcept category
    }

Referral Request

FHIR Messaging, following the Referral Order (O19) message definition, is the FHIR format for sending this model; HL7 v2 OMG^O19^OMG_O19 (360X) is the baseline

• see the PCC-55 example. The message is an aggregate: a collection of FHIR resources sent together, in the same way that HL7 v2 groups segments.

Patient Demographics

Encounter

The encounter in which the referral was made (a GP consultation, a clinic attendance or an admission). Optional; required when a hospital refers onwards during an admission. See Patient Administration.

Referral

Referrer

ORC-12 and ORC-21 are mandatory in this guide - see PCC-55.

Referred To

Reason for Referral

Supporting Information

Clinical content is referenced, not copied into the referral - see Composition, Archetypes and Templates and the BaRS review.

Original, Onward and Redirected Referrals

A referral can give rise to others. Each is the same archetype, created by a different actor:

flowchart TB
    OR["Referral<br/>(from the Referral Initiator)<br/>intent = order"]
    ON["Onward referral<br/>(by the Referral Recipient)<br/>intent = order, basedOn"]
    RD["Redirected referral<br/>(new Referral ID)<br/>replaces"]
    OR -->|"Referral Recipient refers on<br/>(secondary referral)"| ON
    OR -->|"Redirected to another service"| RD

Example: Referral Request - GP to cardiology, sent as Referral Order (O19).