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This guide describes the closed loop referral: a clinician refers a patient to another provider, the provider accepts (or declines) the referral, delivers care and sends the result back, so the loop is closed and the referrer knows what happened. It starts from IHE 360 Exchange Closed Loop Referral (360X) and restates it for the NHS in England.

Why a General Pattern

Referrals, test orders and imaging requests are the same workflow: an order out and a report back. NHS England services each cover a narrow part of it:

None of these covers the whole loop, and none links the report back to the order it answers. This guide uses one pattern - the same one used for laboratory tests in the NW GMSA IG, for cancer pathology in the Cancer Pathology Report IG and for radiology in the Enterprise Imaging IG - so a national service can be shown as one implementation of a step, not as the whole design. See Order and Report Workflow Pattern.

flowchart LR
    A[Referral Initiator<br/>GP, clinician, care plan] -->|Referral Request PCC-55| B[Referral Recipient<br/>outpatients, community,<br/>virtual ward]
    B -->|Accept / Decline PCC-55, PCC-56| A
    B -->|Appointment / No-show PCC-60, PCC-61| A
    B -->|Interim Consultation Note PCC-59| A
    B -->|Referral Outcome PCC-57| A
    A -->|Cancellation PCC-58| B

Principles

• General standards take precedence. IHE profiles, HL7 v2, FHIR (REST, messaging and documents) and CDA define the pattern. NHS England standards are not assumed to be correct: each is assessed against the general pattern, and where it under-specifies the data or the process the general standard is followed and the gap is recorded (see the BaRS review). A national service is one possible implementation of a step, never the design.
• HL7 v2 is the baseline. Most NHS trust systems exchange orders and reports with HL7 v2 through a Trust Integration Engine. Every interaction has an HL7 v2 equivalent, following 360X (HL7 v2.5.1) and the NW GMSA HL7 v2 conventions.
• IHE XDS is optional. 360X carries its messages in IHE XDM or XDR packages. This guide does not assume an XDS registry or XDM/XDR transport; the Exchange Options page gives MLLP, MESH, FHIR messaging, FHIR REST and document sharing alternatives.
• The referral identifier closes the loop. Every message about a referral, in either direction, carries the Referral Initiator's Referral ID (PCC TF-1 X.1.3).
• Share data through APIs; keep messages for workflow. Sharing the record through an API (EU Health Data API: IHE QEDm and MHD) is highly recommended. It significantly reduces the data passed around in messages, leaving messaging to focus on workflow. This is the hoped-for outcome of the NHS England Single Patient Record; the referral and report exchanges are the core of what is often called "write back".
• Reports are FHIR Documents. Outcomes follow HL7 Europe Hospital Discharge Report (HDR), the likely successor to Transfer of Care, and are shared through the EU Health Data API.
• Care settings are not special cases. A referral to a virtual ward (hospital at home) or community service is the same workflow, extended by Dynamic Care Planning.

Contents

Related Guides

• IHE PCC 360X Closed Loop Referral (Rev. 1.2 Trial Implementation, 2021-04-14)
• NW GMSA - laboratory workflow, enterprise integration patterns and the Health Data API; Genetic Referrals applies the same closed loop to clinical genetics
• Cancer Pathology Report and Enterprise Imaging - the same order and report pattern for pathology and radiology
• HL7 Europe Hospital Discharge Report (1.0.0 STU 1) and EU Health Data API (1.0.0-ballot)
• HL7 Physical Activity IG - a recent FHIR referral workflow (ServiceRequest, Task, Observations, Subscription)
• HL7 AU eRequesting - a national FHIR order workflow using ServiceRequest and Task