Ontario eReferral 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:

Basic Referral Directly to a Service, in which a referral is sent directly to a specific health service described in a shared Health Services Directory.
Advanced Referral Directly to a Service, in which, similar to pattern 1, a referral is sent directly to a Service described in a shared Health Services Directory. In this pattern however, the health service information and requested data noted in the Health Services Directory can be supplemented in real time with service-specific clinical decision support information and additional data requirements – such as available appointment slots - to support the request and enhance the business process.

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 family doctor, 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 physician with one secretary who is kept busy answering the phone most of the day. He wants to quickly search “housekeeping”, pick a community service 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 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 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.

Step	Description
1.	Patient visits Primary Care Physician (PCP) as a follow-up from an ER encounter
2.	Upon consultation, the Patient and PCP agree that the Patient would benefit from in-home housekeeping 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 completes and submits the appropriate form to the Service Provider’s RMS. Some of the data in the form has been automatically filled-in from the integrated EMR. This also sends an email to patient, confirming the referral request.
5.	The Service Provider is notified of the incoming referral by their Referral Management System and contacts the patient to arrange housekeeping services
6.	PCP is notified in their RMS and EMR of the date of the first patient encounter when it is arranged by the Service Provider.

Alternate Flows:

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

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 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, 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, 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 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 visits Nurse Practitioner (NP) as a follow-up from previous discussions.
2.	Upon consultation, the Patient and NP agree that the Patient would benefit from a structured exercise program.
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 NP completes and submits the first part of an appropriate form, provided by the NP’s RMS for the selected service, to the Service Provider’s Referral Management System (RMS). 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 Service Provider’s RMS immediately provides the second part of the form for the Patient 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 the NP selects an appointment date, completes Part 2 of the form and submits it.
6.	The NPs integrated RMS informs the Patient by email that the referral has been sent to the Exercise Program Service Provider, and the Service Provider’s RMS provides the Patient with the appropriate appointment information along with a link to change the date if needed.
7.	The Service Provider is notified of the incoming referral by their RMS, the appointment date, and that the Patient has already accepted to appointment date.
8.	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 cancels the service, this status is noted in the NP’s RMS, and in the integrated EMR

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

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 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 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 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 visits Primary Care Physician (PCP) as a follow-up from an ER encounter
2.	Upon consultation, the Patient and PCP agree that the Patient would benefit from home care services.
3.	PCP searches for and selects the appropriate services. Some of the data in the service request form is automatically filled-in from the integrated EMR.
4.	PCP completes and submits the appropriate form in RMS Source to the selected recipient.
5.	RMS Source sends the referral details to the recipient RMS (RMS Target) and notifies the patient by email of 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 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 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 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.