Referral and Transfer of Care Scenarios

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Referral/Transfer of Care Scenarios

Jim McClay

From: [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'; ''; 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.


Referral/Transfer of Care Document Types

Larry Garber

From: [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;; 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.

Referral and Transfer of Care Types

Kevin Coonan, Md

From: [3] On Behalf Of Kevin Coonan, MD Sent: Wednesday, 21 May 2014 2:07 AM To: Grahame Grieve; Chris Hobson; Cc: William Goossen; Stephen Chu; david hay; Subject: Re[2]: Referral and Transition of Care analysis

FHIR Core should include the basic semantics to indicate what responsibility the person making the referral expects the accepting physician/consultant to assume. It would be quite straight forward to pull out a few properties needed to avoid ambiguity, particularly as misunderstanding can be a significant patient safety issue. Some of the expressive may not be 80%, but it would not make sense to put it in an extension.

"Well formed" human-to-human referral/transfer of care (consultations, etc.) include this detail. Transfers are easiest. "What I was doing is now all your responsibility, any further follow up I have with the patient is purely social and/or out of professional interests not related to their direct care." There are often (e.g. in the US) very stringent regulations governing aspects of this (e.g. patient consent, accepting physician, transportation, reason, etc.).

Details follow below. --Kevin


Consultation/referral is where things get messed up. You can consult/refer for a range of participation from the other individual, and if you are not clear about what it is you expect, you will often get unclear results.

Established patterns I have seen include:
1. Consultation for advice/input. I don't want you to do anything besides evaluate the patient/situation and let me know what you suggest. Basically a human powered decision support tool. At times it is needed to be clear about what the evaluation would entail, e.g. diagnostic studies, maybe even some procedure (e.g. biopsy). In general, discussion between parties happens prior to any changes in care plans.
2. Consultation for something I cannot do. Referral/consultation for a procedure. Some 50 y-o biker dude dumps his bike and shows up at the ED/A&E with an open comminuted tib-fib fracture--the good Dr. Chu gets the 2a.m. call that someone needs to go to the OR since I don't do that. For a given scope, the consultant assumes ownership, unless there is some other explicit arrangement (e.g. ortho admits go to the hospitalist).
3. Consultation/referral for specific, on-going, aspects of care. They may assume some aspects of the management, e.g. for a specific disease. They usually act independently in regards to their area of expertise (e.g. makes changes to meds, starts new therapies, initiates new care plans).
4. Referral or consultation for more generalized care from a specialist (e.g. when I ) who has been providing the majority of an individual's care. Often these are people who were previously well, or without access to regular care, with an acute problem which is waning (and/or other issues outside their comfort zone are growing) and need for ongoing, general care (e.g. the guy w/ the busted leg is found to have a 1 cm pulmonary nodule on his chest radiograph, a mild macrocytosis, a borderline ECG, and microscopic hematuria as part of his initial evaluation).
5. Change in disposition. E.g. patient is failing to thrive in home setting and needs placement or home health.

One issue that comes up all the time (esp. in patients referred to ED/A&E from outpatient settings) is that things are discovered during the process which changes the very nature of the referral. E.g. someone sent in to the hospital for admission may be found to have some other diagnosis which can be managed at home, or there is a need for additional 'things' (e.g. febrile infant on antibiotics for 'ear infection' sent to the ED for "Chest X-ray, blood cultures, and a white count" where I also figured out that urine cultures/analysis as well as a lumbar puncture w/ CSF analysis would be indicated and discovered partially treated meningitis). In most areas, if you are the physician seeing a patient, even if someone sent them to you for a very specific reason, you are still responsible for other things, whether you like it or not. So there is always going to be cases when you don't get what you ask for...

If you look at a lot of pre-printed paper consultation forms (or consultation orders in EHRS) many prompt for some of the key aspects, particularly the indication that assumption of care v. answer a question. I would not throw that out in FHIR core.

Aspects to include:
1. For consultations, what is the question?
2. Other consultations/referrals, family members, primary care providers, home health, etc. providers who need to be included in discussions and/or kept in the loop. Simple pig-v-chicken determination.
3. Should the consultant change existing plans?
4. When should discussions with the referring clinician occur?
5. Who is responsible for overall care of the patient? When does this occur.
6. Insurance/coverage limitations, e.g. can the consultant order new consultations or does that need to go to the primary care provider.
7. More?????