Use Case

Referral to Central Access and Triage (CAT)

Description

Requester Health Care Provider sends a referral request to Central Access and Triage (CAT), which manages the referral process

Notes:

A Central Access & Triage model to manage eReferrals may be implemented (provincially, regionally, or locally at organization level) and/or for specific health care specialties/services. While a Central Intake model may primarily focus on administrative processing/scheduling, the CAT model incorporates more comprehensive clinical triage and care coordination processes. Protocols and clinical pathways, developed with input from the health care providers, guide the referral processes. When a CAT model is used, all referral status events flow back to CAT as the owner/manager of the entire referral journey. CAT manages the status of the central (provincial) record and communicates information back to the referring provider as workflow progresses through a central RMS system. This use case assumes that all participants are integrated for electronic message flows; however the workflow requirement allows for both integrated and non-integrated communications (e.g. referral record could be sent via e-fax or other channel).

Scenario

Jayanti is a retired professional athlete. During her career, she experienced a number of injuries which has led to chronic pain challenges. Despite efforts with physiotherapy and medication, the pain in her right shoulder has worsened. Recent imaging (x-ray, ultrasound, and MRI within the past 12 months) has confirmed a deterioration in her condition. Several years ago, Jayanti found relief through joint injections administered by an orthopedic surgeon in another city (where she was previously living).

Based on established clinical pathways, Jayanti’s family physician refers her to an orthopedic specialist for a reassessment and to explore appropriate options for alleviating her on-going discomfort, which may include potential joint injections.

The eReferral is submitted to the Central Access & Triage (CAT) centre. Upon receiving the eReferral, the CAT team reviews the request, prioritizes it based on clinical guidelines, creates a central referral record and assigns the request to an appropriate and available orthopedic specialist.

The medical office assistant at the orthopedic surgeon’s office is notified of the incoming referral request. After reviewing the request, the specialist decides to schedule an in-person appointment with Jayanti and his office assistant contacts Jayanti to schedule an appointment. Updates on the status of Jayanti’s referral is sent to the CAT. Jayanti’s family physician receives updates from the CAT when the appointment is scheduled and completed, to keep her informed about the referral status.

Participants

Refer to Participants for definitions.

Use Case Actors/People	System
Requester Health Care Provider (HCP)	Source System (POS)
Performer HCP	Target System (POS)
Central Access & Triage (CAT)	Central System (RMS)

Pre-conditions

• Valid referral reasons and specialties/sub-specialties for electronic referrals are provided to community EMRs from out of the Health Services Catalogue, and are available to referring providers within their EMRs when they generate an electronic referral.
• Appropriate patient consent in accordance with jurisdictional requirements and legislation, whether implied or expressed, has been obtained to share their personal and health information during the referral process.
• Patient information in Requester POS system is valid
• The Requester Source system has the ability to submit eReferrals in the prescribed format.
• The Performer Target system has the ability to receive and respond to eReferrals in the prescribed format.
• The Performer HCP has registered as a service provider for centrally managed referrals.

Post-conditions

• Primary Flow: The Performer HCP completes the requested service and CAT closes the referral;
• Alternate A: The Performer HCP declines the referral request and CAT closes the referral.
• Alternate B: CAT cancels the referral without assigning it to a Performer HCP;
• Alternate C: The Performer HCP cancels the referral request after it was accepted, and CAT cancels the referral
• Alternate D: The Requester HCP revokes the referral request and CAT closes the referral.

Primary Flow

1. The Requester HCP initiates a referral request.
   • Business Rule – Automatically Populate Referral from EMR Chart: An electronic referral contains the following information, extracted from the referring provider's EMR:
     • Patient identification and demographics
     • Patient contact information – address and telephone number(s)
     • Patient legal guardian or alternate contact information (if applicable) – name, relationship and telephone number(s)
     • Referring provider information – provincial identifier, role, name and related specialty as available / applicable (e.g., sports medicine specialty when referring for orthopedic services)
     • Referring clinic (location) information – provincial identifier, name, address, telephone number(s), fax number
2. The Requester HCP searches for and selects the appropriate service (based on information from the Health Service Catalogue). Available options may be based on referral reason, specialty, and location. The Requester HCP may select the "next available" Specialist or Service Provider, as appropriate to the referral reason, specialty, and location, to receive the referral. Alternately, the Requester HCP may designate a preferred service provider and/or location.
   • Business Rule – Provider Selection of Referral Service: The services that can be requested electronically must be taken from the Health Service Catalogue, with services in effect at the time of the referral. The listing for each service includes the following information:
     • Referral reason
     • Specialty, with sub-specialty as available – corresponding to the referral reason
     • Performer (triage site), including related service zone – for referrals to Central Access and Triage, selection should default based on selected referral reason, specialty, and patient location; can be changed by the referring provider
3. The Requester HCP completes the supporting information needed for the requested service. This includes attaching a referral letter and/or any relevant or required investigations, test results, and reports.
   • Business Rule – Provider Entry of Structured Supporting Information: This information can be captured as structured information in the electronic referral:
     • Reason why the patient is being referred (clinical question) – required
     • Preferred service provider and/or preferred service location – optional, if desired by referring provider and patient prefers a provider and/or location other than 'next available'
     • Priority – defaults to 'routine' (urgent referrals are normally expected to go through other designated channels such as RAAPID)
     • Special considerations for the patient's care – optional
   • Business Rule – Provider Entry of Unstructured Supporting Information: Additional supporting information aligned to provincially standardized contents for quality referrals can be captured in a formatted letter, based on clinician preferences and/or EMR software capabilities, and included in the electronic referral. For example:
     • Current and past management
     • Patient's current status (new or worsening)
     • Patient's medical conditions / medical history, as relevant to the referral (as applicable, based on referring provider's clinical judgment for any particular referral). This may include any combination of medical conditions, allergies, medications, surgical history and/or family history.
     • Patient communication barriers (as applicable)
   • Business Rule – Electronic Referral Attachments: One or more files can be attached to the electronic referral, to be submitted together with discrete data. Attachment sizes must comply with the Central Referral Management System (RMS) file size restrictions (currently 30 Mb per file, with a total attachment size of 150Mb when multiple files are included).
     • Each file must have a unique identifier and a date/time reflecting file creation-date or last-update date.
4. The Requester HCP instructs the EMR system to send the electronic referral to the Central RMS. The submitting EMR formulates the electronic referral data into the standardized structure, and submits through the provincial data hub service.
   • Business Rule – Capture Electronic Referral Record: Submitting EMR system records the electronic referral submission event, and details of the submitted information for subsequent reference and future updates.
     • The EMR assigns and retains a unique identifier for the referral. This identifier will later be matched to the provincially-assigned referral identifier returned by the provincial data hub service.
   • Business Rule – Electronic Referral Submission Metadata: The following submitter metadata is included:
     • Submitting site name and identifier – identifier must be a provincially-issued site identifier that is approved for referral submissions
     • Submitting EMR vendor and product – must be provincially-assigned values
     • Submission implementation guide type and version
     • Service delivery site name and identifier – identifier must be a provincially-issued site identifier for the referring provider’s healthcare delivery site
     • Authoring provider identifier - must be a provincially-issued billing identifier or college license number for the referring provider
     • Submission bundle identifier – a unique identifier assigned by the submitting system, that is unique for each submission (will change on future submissions of the same referral)
     • Submission bundle date and time
     • Submission bundle type – must be the provincially-assigned value for a referral
   • Business Rule – Provincial Referral Terminologies: Data is mapped or associated to the standardized provincial code-sets and terminologies as needed.
   • If Requester HCP subsequently decides to revoke the request, see Alternate Flow D. Note: The Requester HCP can revoke a request prior to it being fulfilled by Performer HCP (step 17).
5. CAT receives the request and creates the central Service Record in the Central Referral System. Timestamp T2 (Referral Received) is populated. CAT communicates the shared referral identifier with the Requester HCP.
   • Business Rule – Provincial Referral Identifier: The EMR system associates the provincially-assigned referral identifier with the submitted referral and displays the identifier to the user. This is to facilitate communication about the referral with other participants in the referral workflow. The EMR system uses the provincially-assigned referral identifier in all future interactions between the EMR system and the Central RMS for the submitted referral.
   • Business Rule – Referral Status: After receiving a workflow status update for the referral, the EMR system updates the referral's status details accordingly: the referral's business status, the date of the status update, and, if applicable, the status reason. The current referral status details are displayed to the end user. The EMR also maintains a status history for the referral which the user can review.
6. CAT reviews the request for adherence to business rules for referral contents.
   • If CAT needs additional information, see Additional Flow i.
   • If CAT decides to cancel the request, see Alternate Flow B.
7. CAT assigns the request to an appropriate Performer HCP and the Central System sends the referral record to the Performer HCP
8. CAT notifies the Requester HCP that the referral record is now updated with the Performer assignment.
9. The Performer HCP acknowledges receipt of the newly assigned referral request. Performer Target System initiates the corresponding Performer workflow.
10. The Performer HCP reviews the referral request.
    • If Performer HCP requests information from the Requester HCP, see Additional Flow ii.
11. Performer HCP agrees to perform the requested service.
    • If the Performer HCP declines the request, see Alternate Flow A.
12. CAT receives the accepted status from the Performer HCP, and updates the state of the central referral record as applicable.
13. CAT notifies the Requester HCP that the referral record is now updated with a status indicating acceptance by the Performer HCP.
14. The Performer HCP schedules the appointment for the patient consultation, and the Target System sends the appointment details to the CAT Central System.
    • If Performer HCP decides to cancel the request after previously accepting it, see Alternate Flow C.
15. CAT receives the appointment details from the Performer HCP, and updates the state of the central referral record as applicable.
16. CAT informs the Requester HCP of the scheduled appointment.
17. The Performer HCP fulfils the requested service through the patient consultation appointment, and notifies CAT that the performer workflow is complete.
18. CAT receives the completed status from the Performer HCP, and updates the state of the central referral record as applicable.
19. CAT notifies the Requester HCP that the referral record is now updated with a status indicating completion of the requested service.

Additional Flows

The following are extra steps/processes that may be added to the primary workflow to handle specific circumstances or requirements.

i. CAT requests additional information from Requester HCP

• The CAT needs more information from the Requester HCP before they can assign the request to the Performer HCP.

1. CAT documents the additional information needed, and sends the information request to the Requester HCP.
2. Requester HCP receives the request and gathers the information needed.
3. Requester HCP updates the service request with the additional information (e.g. attached supporting info) and/or separately documents a communication containing their response; then sends the assembled response to CAT.
4. Use case flow returns to primary flow for assignment of the Performer HCP.

ii. Performer HCP requests additional information from Requester HCP

• The Performer HCP needs more information from the Requester HCP.

1. Performer HCP documents the additional information needed and sends the information request to CAT to manage as part of the central referral record.
2. CAT receives the information request from the Performer HCP, and updates the state of the central referral record as applicable.
3. CAT incorporates any centrally managed information to the Performer HCP information request as needed, and sends to the Requester HCP for response.
4. Requester HCP updates the service request with the additional information (e.g. attached supporting info) and/or separately documents a communication containing their response; then sends the assembled response to CAT.
5. CAT receives the information response from the Requester HCP, and updates the state of the central referral record as applicable.
6. CAT sends the response information to the Performer HCP.
7. Use case flow returns to primary flow for the performer to review and resume related workflow.

iii. CAT redirects referral request to a new Performer HCP

• CAT may redirect the case to a different Performer HCP. Reasons for this can vary and may include case declined by Performer HCP. This does not close the referral request but rather redirects it to a new Performer HCP.

1. CAT receives the declined information from the Performer HCP that indicates they cannot fulfill the request as assigned.
2. CAT identifies an alternate service provider for the referral request, and replaces the assigned Performer HCP.
3. Use case flow returns to primary flow where workflow re-starts under the new performer.

Alternate Flows

The following are processes/pathways that achieve a different outcome from the primary workflow based on specific circumstances or requirements.

A. Performer HCP declines request

• The Performer HCP decides to decline the referral request after reviewing it. The Performer HCP updates the referral status and includes a reason for declining the request (e.g., unable to provide the service) in the Target System. An update is sent to CAT.

1. Performer HCP determines either that the service cannot or should not be fulfilled as requested, or that the referral request is appropriate but cannot be fulfilled as assigned; then notifies CAT of the declined request along with details of the reason for declining.
2. CAT receives the declined information from the Performer HCP, and updates the state of the central referral record. If the request is redirected to a new performer, see Additional Flow iii
3. CAT notifies the Requester HCP that the referral record for the referral request has now been updated to indicate a declined service, including the decline reason.
4. CAT closes the referral.

B. CAT cancels the referral request

• After completing clerical triage, CAT decides to cancel the referral request prior to assigning to a Performer HCP. CAT updates the referral status and includes a reason for cancelling the request (e.g., referral does not meet criteria appropriateness) in the Central System. An update is sent to the Requester HCP.

1. CAT determines that the service cannot be fulfilled as requested, updates the state of the central referral record with the cancellation along with details of the cancellation reason, and notifies the Requester HCP.
2. Requester HCP receives the cancellation from CAT and updates its record.

C. Performer HCP cancels referral

• The Performer HCP decides to cancel the referral after having previously accepted it. The Performer HCP updates the referral status and includes a reason for cancelling the request (e.g., patient has been unsuccessful attending appointments) in the Target System. An update is sent to CAT.

1. Performer HCP determines that the service cannot be fulfilled as requested, and notifies CAT of the cancelled request along with details of the reason for cancellation.
2. CAT receives the referral cancellation from Performer HCP and CAT updates the central referral record.
3. CAT notifies the Request HCP that Performer HCP has cancelled the referral, including the cancellation reason.
4. Requester HCP receives the cancellation from CAT and updates its record.

D. The Requester HCP revokes the referral

• The Requester HCP determines that patient no longer requires the referral and decides to revoke the request. An update is sent to CAT.

1. The Requester HCP revokes the referral and notifies CAT.
2. CAT receives the referral revocation from Requester HCP and updates the central referral record.
3. If the referral was previously sent to and accepted by Performer HCP,
   • 3.1 CAT also notifies the Performer HCP that the Requester HCP has revoked the referral.
   • 3.2 Performer HCP receives the referral revocation and updates its record.
4. CAT closes the referral.