Ontario eReferral - eConsult HL7® FHIR® Implementation Guide

Use Cases

As referral pathways are defined and implemented, they can be characterized by repeating patterns based on both the underlying technology and the referral workflow. As such, the patterns in scope are derived from the following use cases and intended to provide generic guidance for various pathway implementations. Please note that both eConsult and eReferral might be integrated into one application to serve the business collaboratively and hence these use cases should be interpretted accordingly.

Use Case #1: Referral to Service

Jane Doe is an independent senior who lives alone. She has had a recent injury that resulted in an ER visit, and has a follow-up appointment with her Healthcare Provider, Dr. Jones who notices her appearance is not as crisp as usual. Jane admits she is struggling with keeping up with laundry and other chores due to her injury and Dr. Jones believes she would benefit from some housekeeping services. He is a busy Healthcare Provider with one secretary who is kept busy answering the phone most of the day. He wants to quickly search “housekeeping”, pick a community service (non-HIC) close to Jane and send a referral. Dr. Jones knows from previous experience that this referral will not get lost like a fax, and he can expect an update on the request via his email and within the patient/client record.

Dr. Jones initiates a search for the service from his EMR, which is integrated with a Referral Management System (i.e. RMS Source). After selecting a housekeeping service appropriate to Jane, he is presented with a form with some of the information already automatically filled in with data from his EMR. He completes the form and clicks Submit to send the referral request details to the Service Provider’s Referral Management System (i.e. RMS Target), and an email to Jane confirming that the referral has been requested.

The RMS Target notifies April, the Service Provider representative, of the incoming request who contacts Jane using her preferred method of communication and arranges the appropriate services. The RMS Target also updates Dr Jone’s RMS Source, which in turn updates Dr.Jones’ EMR that Jane has had services set-up, and with their on-going status.

Note: If the recipient is not a Health Information Custodian (HIC) or an agent acting on behalf of the HIC, then the family doctor is required to obtain the individual's express consent prior to disclosing any PHI to the other provider. The content in this implementation guide is intended to provide general information only; it is not intended to provide business, professional, medical or legal advice, or to answer specific questions.

Step	Description
1.	patient/client/Client visits Primary Care Physician (PCP) as a follow-up from an ER encounter.
2.	Upon consultation, the patient/client/client and PCP agree that the patient/client would benefit from in-home housekeeping services and the patient/client provides express consent to the disclosure of their PHI to the recipient of the referral
3.	PCP searches for and selects an appropriate service from a Services Catalogue, which is integrated with the EMR and the PCP’s Referral Management System (RMS).
4.	PCP is presented with and completes the appropriate referral form for the Service Provider. Some of the data in the form has been automatically filled-in from the integrated EMR.
5.	PCP submits the form to the Service Provider’s RMS. This also sends an email to patient/client, confirming the referral request.
6.	The Healthcare Provider is notified of the incoming referral by their Referral Management System and contacts the patient/client to arrange housekeeping services.
7.	PCP is notified in their RMS (which acts as a single access point) and EMR of the date of the first patient/client encounter when it is arranged by the Service Provider.

Alternate Flows:

• If the Healthcare Provider is unable to provide the requested services, this status is noted in the Referral Management System, and automatically forwarded to the PCP EMR

• If the patient/client declines the service, this status is noted in the Referral Management System, and automatically forwarded to the PCP EMR

HIC consent obligations under PHIPA:

Depending on the specific use case, if the HIC requires consent (implied or express) to collect, use or disclose personal information, the HIC must ensure that individual knows the purposes for the collection, use or disclosure.

Assumptions

• PCP EMR is integrated with Referral Management System

Use Case #2: Referral to Service with Booked Appointment

John Doe is a complex senior patient/client who lives alone. He has a Nurse Practitioner(NP) who is working very closely with him with both medical and social issues. John could use some exercise, but really the NP wants to give him a reason to leave his home and socialize. She suggests Gentle Exercise classes with a non-HIC community services provider, and he begrudgingly agrees. The NP knows that if left up to him, he will not pursue this further, so she wants to send him home with a day,time and location for at least one class. She is confident that the referral recipient will get all the information they need, pulled from her EMR (patient/client information, PHI and non-PHI), and together they find a location, date and time that will work for him. The NP is willing and able to sign him up for his class and complete all the necessary details in the sign-up form. Afterwards she prints off what he needs to take home, and also knows that an email will be waiting for him when he gets home. She is happy that she does not need to duplicate the information from the referral in his patient/client record as this has automatically updated for her in her EMR.

The community service provider is notified that John has signed up for this specific class and is able to take appropriate action.

Step	Description
1.	patient/client visits Nurse Practitioner (NP) as a follow-up from previous discussions.
2.	Upon consultation, the patient/client and PCP agree that the patient/client would benefit from in-home housekeeping services and the patient/client provides consent to the disclosure of their PHI to the recipient of the referral.
3.	The NP searches for and selects an appropriate Exercise Program from a Services Catalogue, which is integrated with the EMR and with the NP’s Referral Management System (RMS). ** * **
4.	The RMS presents the NP with an appropriate two part form for the selected service, and the NP completes the first part. Part one of the form is based on the service details in the Services Catalogue, and some of the data in the form has been automatically filled-in from the integrated EMR.
5.	The NP submits the first part of an appropriate form to the Service Provider’s Referral Management System (RMS).
6.	The Service Provider’s RMS immediately provides the second part of the form for the patient/client and NP to complete. Part 2 of the form includes real-time information from the service provider, such as available appointment slots, and other service-specific details such as clinical decision support information and additional data requirements that may not have been included in the more generic Service Catalogue information. In consultation with the patient/client the NP selects an appointment date, completes Part 2 of the form and submits it.
7.	The NPs integrated RMS informs the patient/client by email that the referral has been sent to the Exercise Program Service Provider, and the Service Provider’s RMS provides the patient/client with the appropriate appointment information along with a link to change the date if needed.
8.	The Service Provider is notified of the incoming referral by their RMS, the appointment date, and that the patient/client has already accepted to appointment date.
9.	The NP is automatically updated in both their EMR and their integrated RMS of status changes related to the referral to the Exercise Program.

Alternate Flows:

• If the Service Provider is unable to provide the requested services, this is noted in Part 2 of the form, the NP’s RMS, and in the integrated EMR

• If the patient/client cancels the service, this status is noted in the NP’s RMS, and in the integrated EMR

** * ** In case the patient/client requires more than one service, the health care provider should be capable of generating more than one referral or consult requests.

HIC consent obligations under PHIPA:

Use Case #3: Referral to Home and Community Care through Care Coordinator

Basic Flow

Jane Doe is an independent senior who lives alone. She had a recent injury due to a fall at home that resulted in an ER visit. In a follow-up appointment, Dr. Jones, her family doctor, notices her appearance is not as crisp as usual. Jane admits she is struggling with keeping up with the house chores due to her injury and that she is also afraid of falling again.

Dr. Jones suggests that she might benefit from some personal support services and maybe other home related services to help her cope with her condition. Once Jane provides express consents to being referred for home care services Dr. Jones searches for homecare services from his electronic medical record (EMR), which is integrated with a Referral Management System (i.e. RMS Source). He selects the LHIN which provides coordination for all home care services in the region Jane resides. He is presented with a referral form which is prepopulated with some of the patient/client information from his EMR.

From the list of available services on the referral form Dr. Jones selects the personal support service option and the home safety assessment option. Dr. Jones continues to fill out the form by identifying the primary diagnosis, the reason for referral, any allergies Jane may have. Then he includes the contact information for Jane's daughter that lives in the Barrie.

Dr. Jones decides the information selected on the form is appropriate for Jane's condition and he clicks ‘Submit’ to send the referral request to South East LHIN Referral Management System (i.e. RMS Target). The RMS Source System determines that Jane has signed up for email notifications and sends Jane an email to confirm that the referral has been requested.

The RMS Target notifies April May, a South East LHIN Care Coordinator, of the incoming referral. April upon receiving the notification reviews the referral information, marks the referral "Accepted" in the RMS Target and includes a note to indicate the patient/client will be assessed for home care services over the phone. The RMS Target notifies the RMS Source of the acceptance. The message is conveyed to the Dr. Jones in the RMS Source system.
April then contacts Jane over the phone to find out a few more details about her home setting. While talking to Jane April documents the responses in the InterRAI Contact Assessment tool/form. After this, April documents the encounter in her system of record and determines that Jane is eligible for home care services offered through the South East LHIN.

April proceeds to create a service plan for Jane and orders personal support services and occupational therapy services (for the home safety assessment) from the Acme Care Enhanced Services Inc. (ACES) agency. Once completed April marks the referral "Completed" in the RMS Target. The RMS Target prompts April to select service plan items to be included as a service summary in the completion message.

Jane selects both services ordered from ACES on Jane's behalf and submits the update. The RMS Target sends the completion notification to RMS Source, including the service plan summary and any additional details April chose to include. The RMS Source notifies Dr. Jones of the referral completion and sends an email notification to Jane to keep her informed of the referral outcomes.

Step	Description
1.	patient/client visits Primary Care Physician (PCP) as a follow-up from an ER encounter
2.	Upon consultation, the patient/client and PCP agree that the patient/client would benefit from home care services.
3.	PCP searches for and selects an appropriate service from a Services Catalogue, which is integrated with the EMR and the PCP’s Referral Management System (RMS).
4.	PCP is presented with and completes the appropriate referral form for the Service Provider. Some of the data in the form has been automatically filled-in from the integrated EMR.
5.	PCP submits the form to the Service Provider’s RMS. This also sends an email to patient/client, confirming the referral request.
6.	The Care Coordinator (the recipient) is notified of the incoming referral by RMS Target and reviews the referral details.
7.	The Care Coordinator confirms the referral acceptance in RMS Target and the message along with any optional note is conveyed to the PCP by the RMS Source.
8.	Upon assessing the patient/client for home care services the Care Coordinator creates the service plan and orders services from an SPO.
9.	The Care Coordinator updates the referral status to Completed in the RMS Target and includes the ordered service details in the communication as a service summary, identifying that ACME will start delivering the requested services on a certain date.
10.	The RMS Target sends the referral status update including the service summary and any additional details specified by the Care Coordinator to RMS Source system.
11.	The RMS Source notifies the PCP in their EMR of the referral update and at the same time notifies the patient/client by email of the referral outcome.

Alternate Flows

Alternate Flow #1 – Request For Information (RFI)

Upon reviewing the initial referral details, April determines more information is required because an Occupational Therapy (OT) report should be attached to the referral. April sends an RFI request from the RMS Target system to the RMS Source system to notify PCP of the additional information. Dr. Jones reviews the RFI request in the RMS Source system and decides to update the referral with an attached OT Report (the document attachment is attached to the referral by RMS Source). April receives the referral update in RMS Target and processes the referral to completion using the remaining steps in the basic flow.

Alternate Flow #2- Referral Updates

Upon submitting the initial referral Dr. Jones determines Jane should also be assessed for Long Term placement by the SE LHIN. He discusses this possibility with Jane on her subsequent scheduled visit and Jane agrees to consider this possibility. Dr. Jones updates the initial referral to add the “Assessment: Eligibility for Long term care home” service and commits the update in the RMS Source. April receives the updated referral request including the new service in her RMS Target system and processes the modified referral request to completion using the remaining steps in the basic flow based.

Alternate Flow #3 – Cancellation

Dr. Jones is notified in his EMR (out of scope for this workflow) that Jane condition has changed and she is now admitted to an in-patient/client unit at the local hospital. Not knowing when Jane’s condition will improve in order to live independent in the community Dr. Jones decides to cancel the home care referral in the RMS Source system. RMS Source sends the cancellation message to the RMS Target and notifies Jane by email that her initial referral has been cancel due to her stay in the hospital. April receives the referral cancellation notification in the RMS Target. If the service plan has already been created, she discharges the services ordered with ACME (which will receive an automatic notification, out of scope for eReferral flow) and closes Jane file.

HIC consent obligations under PHIPA:

Use Case #4: Consultation Request

In eConsult workflows, cases can be submitted to a managed speciality, directly to a specialist, or to a managed group.

In the managed specialty option, cases can be submitted to a regionally managed specialty, which is a group of consultants responding to eConsult cases for a given specialty or sub-specialty (e.g. Pediatric Cardiology). The case will be routed to the nearest Regional Managed Specialty or a Provincial Managed Specialty if a local one is not available. Cases are assigned based on an algorithm which takes into account the consultants' availability, case volume, and preferred max cases.

In the direct to specialist option, the assigner or delegate will search for and select a specific specialist to be the recipient of the consult request. In this option, the provider can also conduct a search on a specialty and select an organization that provides a specific specialty. A case manager at the organization receives the request and routes it to a specialist.

The Use Case listed below will present both options as variations.

Use Case

Jane Doe visits her family doctor complaining about pain occurring in her back and lower abdomen for the past two days. The family physician assessment notes right-sided flank pain radiating from the back to the lower abdomen, with fluctuating intensity that has not resulted in fever, nausea or vomiting. The patient/client has not had any recent trauma, numbness or weakness in extremities, and no saddle anesthesia. Suspecting renal colic, Jane's doctor sends her for an ultrasound. The ultrasound confirms a non-obstructing 5mm stone in the right ureter but also find an incidental complex renal cyst.

Jane's family physician decides to consult a urologist to ask if the cyst can be managed with serial imaging, or whether a referral and consideration of a biopsy is necessary.

Variation 1 - Request to Managed specialty (direct from RMS Source)

Jane's family physician initiates the eConsult request, searches for the specialty - Urology, and then creates and submits an eConsult case.

The case is received by the Case Manager at the managed specialty who assigns the case to a Urologist.

Variation 2 - Case submitted to Specific Provider

Jane's family physician knows a Urologist whom they wish to submit the consult request to directly. The family physician initiates the eConsult request, searches for the specific provider, and then creates and submits an eConsult case.

Variation 3 - Managed Group

Jane's family physician know which organization to submit the consult request to but will leave it to the case assigner at the organization to select the specialist. The family physician creates the eConsult request, searches for an organization, and submits the case to the organization.

After Case Assignment

The Urologist receives a notification for the assigned case, logs into their Referral Management System (RMS Target), reviews the case details and sends a response back to Jane's family physician indicating that the size of the cyst and characteristics reported on the ultrasound can be safely monitored. A repeat Ultrasound is recommended within 6 months. Upon returning the consult, the Urologist is prompted to fill out a brief survey indicating time spent on the case amongst other questions.

Jane's family physician receives the consult result, reviews the notes left by the Urologist, is satisfied with the response and no further clarification is necessary at this time. The family physician closes the case from the Referral Management System. Upon closing the case, the family physician is prompted to fill out a brief survey.

Step	Description
1.	patient/client visits Primary Care Physician (PCP) with a complaint about pain.
2.	After reviewing imaging in patient/client chart, the PCP seeks input from urologist.
	Variation 1
3.a.1	Using a Services Catalogue which is integrated with the EMR and the PCP’s Referral Management System (RMS), the PCP searches for a case recipient using the Managed Specialty model.
3.a.2	The PCP selects Urology and Urology - General as the specialty and sub-specialty for the service.
3.a.3	The solution auto selects a default Managed Specialty based on location. (The PCP has the option to override the default selection.)
3.a.4	The PCP writes the question for the specialist, attaches an image and other notes to support the request.
3.a.5	The PCP submits the consultation request.
3.a.6	The PCP receives a notification in the EMR that the request was successfully submitted.
3.a.7	Case Assigner assigns case to Urologist, or the case gets automatically assigned by the system.
	Variation 2
3.b.1	The PCP searches for and selects a specific Urologist.
3.b.2	The PCP writes the question for the specialist, attaches an image and other notes to support the request.
3.b.3	The PCP submits the consultation request.
3.b.4	The PCP receives a notification in the EMR that the request was successfully submitted.
	Variation 3
3.c.1	The PCP searches for and selects the managed group.
3.c.2	The PCP writes the question for the specialist, attaches an image and other notes to support the request.
3.c.3	The PCP submits the consultation request.
3.c.4	The PCP receives a notification in the EMR that the request was successfully submitted.
3.c.5	The Assigner of the Specialty group receives an email notification for the new case, logs into the RMS system. The Assigner views the case alongside others pending assignment. The Assigner assigns the case to a Specialist.
	After Case Assignment
4.	The Specialist receives an email notification on the arrival of the new case.
5.	The Specialist access the eConsult through the RMS, or their EMR/HIS which is integrated with the RMS, and responds to the consult by entering in notes and/or attachments.
6.	The Specialist is prompted to enter in time spent on the case and answer other survey questions.
7.	The PCP receives an email notification indicating that a consult has been provided.
8.	Using the EMR and the Referral Management System (RMS), the PCP reviews the response, is satisfied with the information, and completes the case.
9.	Upon case completion, the PCP is prompted to fill out a survey which helps to measure the performance of the eConsult application. The PCP also provides feedback to the Specialist.

Alternate Flows

Alternate Flow #1 - Request For More Info

Upon reviewing the consult request, the Urologist notices the Ultrasound report is missing from the case. The Urologist sends a Request For More Info back to the PCP asking for the report to be attached.

Alternate Flow #1a - Provide More Info

The PCP responds to the Request for More Info by attaching the Ultrasound report to the case.

Alternate Flow #2 - Cancel Case

After submitting the case, the PCP decides they no longer require a consult with a Urologist and cancel the case request.

Alternate Flow #3 - Request Clarification

The Urologist provides the consult back to the PCP, however, the PCP has some follow up questions for the Urologist. The PCP responds to the case requesting clarification.

Alternate Flow #4 - Assigner Re-assigns Case

The Assigner notices that the case has been sitting idle for a number of days and decides to assign the case to another provider.

Alternate Flow #5 - Case Redirected by Requester

The consult is provided but the PCP wants a second opinion. The PCP redirects the case to another provider. In the system, this closes the original case and create a new request for the recipient.

Alternate Flow #6 - Return Case (Specialist)

The Urologist remembers they will be away for a period of time and will not be able to respond to the case in a timely fashion. The Urologist returns the case with a reason of 'Not Available'. The case goes back to the Assigner who then assigns the case to another specialist.

Alternate Flow #7 - Return Case and convert to eReferral

The Urologist provides the consult but wishes to see the patient/client. In the Referral Management System, the Urologist provides the consult and selects the option to indicate they wish to see the patient/client. The PCP completes the consult and initiates a referral.

HIC consent obligations under PHIPA:

Use Case #5: Convert Referral to Consultation

John Doe visits his family physician to report chest pain occurring over the weekend. John is a smoker, with high blood pressure and high cholesterol. After a thorough assessment, the family doctor does not think the chest pain is cardiac in origin but is not certain due to the risk factors in John's past medical history. The doctor proceeds to create a Referral to a Cardiologist. The Cardiologist responds to the referral request by providing a consult suggesting the family physician first send the patient/client for a non urgent echocardiogram and exercise stress test.

Step	Description
1.	patient/client visits Primary Care Physician (PCP) to report chest pain and presents past medical history.
2.	The PCP initiates an eReferral request from their Referral Management System (RMS Source) to a Specific Cardiologist.
3.	The cardiologist receives a notification for the eReferral in their Referral Management System (RMS Target), reviews the request, and responds by providing a consult instead of booking the patient/client in for an appointment. Specialist is prompted to submit time spent on the case to provide eConsult advice.

HIC consent obligations under PHIPA: