Referral and Transfer of Care Scenarios

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Referral/Transfer of Care Scenarios

Jim McClay

From: owner-patientcare@lists.hl7.org [1] On Behalf Of McClay, James C Sent: Thursday, 22 May 2014 12:53 AM To: Chris Hobson; 'Grahame Grieve' Cc: 'William Goossen'; Stephen Chu; 'david hay'; 'patientcare@lists.HL7.org'; fhir@lists.hl7.org Subject: RE: Referral and Transition of Care analysis

Hi, Grahame is right, clinicians never get this right because much of the handoff to consultants is based on traditional referral relationships.

This problem has been debated in numerous forums over the years. When we explored the problem at our site we decided we needed to make the consult process specific as to what was expected of the consultant. After much debate we settled on a hierarchy of reponsibilities.

Because every vendor's software is different I will generalize the categories as I understand them. We can represent these in one resource with a flag or a profile for the specific type of handoff.

1) Refer for second opinion, communicate recommendations to referring physician.

   This is often how a referral to neurology works.

2) Refer for specific issue: referal physician to assess and treat the specified issue in communication with primary

   This is  typical of referral to cardiology

3) Refer for specific procedure: the referal physician assesses, sets up, and performs procedure

   This is a typcial workflow for hernia repair, colonoscopy, etc.

4) Refer for primary management of patient: referal physician takes over primary management of the patient for the duration of an episode

   Patients placed in the ICU or under treatment trauma are in this category

5) Complete transfer of care: The referal physician becomes the primary provider. If the patient is returned to the originating provider it is another complete transfer of care. Otherwise known as a handoff.

   There are two forms of this. Short term and long term. Short term is the typical shift change or weekend coverage. We do this very poorly and it is the source of significant morbitity and mortality. The long term handoff is typical of a transfer of care from one site to another.

Jim

Referral/Transfer of Care Document Types

Larry Garber

From: owner-patientcare@lists.hl7.org [2] On Behalf Of Garber, Lawrence Sent: Tuesday, 20 May 2014 7:58 AM To: Grahame Grieve; Chris Hobson Cc: William Goossen; Stephen Chu; david hay; patientcare@lists.HL7.org; fhir@lists.hl7.org Subject: RE: Referral and Transition of Care analysis

Referrals for consultation (including visits to the Emergency Department) is a case of “Shared care” where I as the primary care physician still maintain primary responsibility for the care of that patient. I’m just asking for help with a particular condition or need a specific test/procedure. Thus I do not need to send the same level of exhaustive detail about the patient. Dr. O’Malley did this analysis based on 1000+ surveys (see the HL7 presentation from Boston that was referenced) and identified the following datasets in order of increasing number of data elements:

1. Report from Outpatient testing, treatment, or procedure
2. Referral to Outpatient testing, treatment, or procedure (including for transport)
3. Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility) (AKA Consultation Note)
4. Consultation Request Clinical Summary (Referral to a consultant or the ED) (AKA Referral Note)
5. Permanent or long-term Transfer of Care Summary to a different facility or care team or Home Health Agency

While these were defined by the receivers, their scenarios are distinct and known in advance by the sender and could be pre-programmed into the EHR (Referral orders to Neurology require #4. Release of information for “new PCP” or referral orders to Home Health require #5. Consultation note or ED note back to PCP require #3. Request for colonoscopy order requires #2. Colonoscopy report requires #1….)

Larry Garber, M.D.