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

Order and Report Workflow Pattern

A referral, a laboratory test and an imaging examination follow the same workflow: the placer sends an order, the filler accepts it, does the work and sends a report. IHE defines this pattern separately for each domain; this page shows they are one pattern, so a referral can reuse what NHS trusts already run for pathology and radiology.

References

• NW GMSA - Laboratory Testing Workflow (LTW) and Architecture - Enterprise Integration Patterns
• Cancer Pathology Report - LTW and ILW
• Enterprise Imaging - Radiology Scheduled Workflow (SWF.b)
• IHE PCC 360X
• FHIR Workflow - Request, Event and Task and Workflow Management Communication Patterns
• IHE Medication Prescription and Delivery (MPD) and the Electronic Prescription Service
• Enterprise Integration Patterns

One Pattern, Several Domains

sequenceDiagram
    participant P as Placer<br/>Order Placer / Referral Initiator
    participant F as Filler<br/>Order Filler / Referral Recipient
    P ->> F: Order
    F -->> P: Accept / reject (status)
    opt Scheduling
        F -->> P: Appointment / scheduled
    end
    F -->> F: Carry out the work
    opt Interim results
        F ->> P: Preliminary report
    end
    F ->> P: Final report (closes the loop)
    opt
        P ->> F: Cancel
        F -->> P: Cancel confirmed
    end

360X uses the same HL7 v2.5.1 segments (ORC, OBR, OBX, TQ1) as LTW and SWF.b, so the mappings already agreed in the NW GMSA HL7 v2 conventions apply. The difference is the report: a test returns results (DiagnosticReport and Observation), a referral returns a clinical document (consultation note, discharge report or care plan).

FHIR Workflow

In FHIR the same pattern is a Request (ServiceRequest), the work done (Task, Encounter, Appointment) and an Event (DiagnosticReport, Composition):

flowchart LR
    SR[ServiceRequest<br/>the referral] --- T[Task<br/>workflow state]
    T --> A[Appointment]
    T --> E[Encounter]
    E --> C[Composition<br/>consultation note /<br/>discharge report]
    C -. basedOn .-> SR
    DR[DiagnosticReport<br/>test result] -. basedOn .-> SR2[ServiceRequest<br/>the test order]

In every case the report references the order (basedOn). This is the link that closes the loop, and the one most often missing from NHS letters today.

Integration Layers

The NW GMSA enterprise integration view describes the layers NHS organisations build up. Referral workflow can be delivered at each layer; the NHS England services sit at different layers:

graph TD
    DM["<b>Document Messaging</b><br/>HL7 v2, FHIR Messaging, MESH<br/>eRS (attachments), Transfer of Care, Kettering XML,<br/>GP Connect Send Document / Update Record"]
    DS["<b>Document Sharing</b><br/>Health Data API / IHE MHD, NRL<br/>IHE XDS (optional)"]
    RS["<b>Data / Resource Sharing</b><br/>Health Data API / IHE QEDm, IPA<br/>shared care records, GP Connect Access Record, IM1"]
    EN["<b>Event Notifications</b><br/>NHS MNS, FHIR Subscription, DSUBm"]
    CW["<b>Conversational Workflow</b><br/>FHIR Task, BaRS, eRS API, EPS<br/>IHE DCP"]
    DM --> DS
    DM --> RS
    DS --> EN
    RS --> EN
    EN --> CW
    classDef base fill:#D5E8D4;
    class DM base

Sharing data through an API (Document and Resource Sharing, see EU Health Data API) is highly recommended: it significantly reduces the data carried in messages and leaves messaging to focus on workflow.

This guide's interactions work at the Document Messaging layer first (HL7 v2 or FHIR messages, see Exchange Options), because that is where most NHS systems are, and show how they move to the other layers without changing the data.

The Narrow Focus Problem

Each NHS England service implements part of the pattern for one setting:

The NHS England Referral and Report Services and NHS England Diagnostic Order Services appendices assess each of these against the 360X transactions. Where a national standard is narrower than the general pattern, or under-specifies its data or process, the general standard takes precedence: implementations follow IHE / HL7 / FHIR, and the national service is mapped to it, not the other way round. eRS and EPS are well engineered within their scope and can be used as references for referral triage and for prescribing.