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UC-01: Referral directly to a Service Provider

UC-01: Description

Requester Health Care Provider sends a referral request directly to a Performer Health Care Provider

UC-01: Scenario

Jane Doe is an active 72 year old who is managing type 2 diabetes, osteoarthritis (multiple joints), and chronic neck pain. Her neck pain had been well controlled with a combination of oral and topical medications, physiotherapy and massage therapy. However, in the last few months, Jane’s neck pain has worsened, exhibiting more concerning features.

Jane attends an appointment with her family doctor, Dr. Jones, who reviews past imaging results, including a fairly recent MRI. Dr. Jones determines that the underlying cause of the pain requires further assessment and refers Jane to a specialist.

Dr. Jones creates an eReferral and selects a neurosurgical specialist that is located close to Jane’s home. After selecting the specialist, referral requirements are presented on his screen with some of the information already filled in (based on available data from his EMR). He completes the referral requirements and sends the referral request to the specialist.

The medical office assistant at the neurosurgical specialist’s office is notified of the incoming referral request. After reviewing the request, the specialist decides to schedule an in-person appointment with Jane and his office assistant contacts Jane to schedule an appointment. Updates are electronically sent to Dr. Jones when the appointment is scheduled and completed to keep him informed about the referral status.

UC-01: Participants

Please refer to Participants for definitions.

People	Systems
Requester Health Care Provider (HCP)	Source System (POS or RMS)
Performer HCP	Target System (POS or RMS)

UC-01: Triggers

Requester HCP needs to refer a patient for services with another provider (e.g., specialty care)

UC-01: Pre-conditions

• The Source System/Target System used by the healthcare provider is a) a point of Service (POS) system that includes RMS capability, or b) a Referral Management System (RMS) that is integrated with the POS system.
• The Source System is integrated with a valid and up-to-date Health Services Directory
• 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.
• The Source System has the ability to submit referral requests in the prescribed format.
• The Target System has the ability to receive and respond to referral requests in the prescribed format
• Patient information in Source System is valid.

UC-01: Post-conditions

• Primary Flow: The Performer HCP completes the initial consultation appointment with the patient and completes the referral request;
• Alternate A: The Performer HCP declines the referral request;
• Alternate B: The Performer HCP converts the referral to a consultation; (See UC-02: Provider-to-Provider Consultation Request)
• Alternate C: The Performer HCP cancels the referral request after it was accepted;
• Alternate D: The Requester HCP revokes the referral request.

UC-01: Workflow diagram

This use case diagram represents the participants and their role in the use case with a high-level view of the clinical and information workflow.

Please see Sequence Diagrams for UC-01: Referral to a Service for a technical sequence diagram implementing this use case.

UC-01: Primary Flow

The following provides a textual description corresponding to the use case diagram.

1. Requester HCP initiates a referral request.

2. Requester HCP searches for and selects the appropriate service and/or service provider (based on results from the Health Service Directory).

   For implementation guidance on interactions with a Service directory, please refer to the pan-Canadian Care Service Directory (CA:CSD)

3. Requester HCP is presented with and completes the referral requirements. Patient information and some of the referral requirements may be automatically populated based on information available in the POS system.

4. Requester HCP may provide a clinical narrative to support the reason for the referal and/or attach additional clinical notes/supporting documentation from the POS system to support the referral request.

5. Requester HCP submits the referral request with the required information and clinical documentation. The Requester (Source system) transmits the referral request to the Performer (Target system).

6. The Performer (Target system) receives the referral request. The Performer HCP receives a notification about the new referral request.

7. The Performer HCP reviews the request.

   Note:The request may be received and initially reviewed by administrative/support staff at the specialist’s office before being reviewed by the specialist.

8. The Performer HCP accepts the request, and an appointment is booked with the patient. The Performer HCP updates the referral status. The Performer (Target system) transmits an update to the Requester HCP (Source system).

   If the Performer HCP declines the request, see Alternate Flow A and B.

9. Performer HCP completes the initial consultation appointment with the patient. The Performer (Target system) transmits an update to the Requester (Source system).

UC-01: Additional Flows

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

i. The Performer HCP needs additional information (after step 5 and before step 8)

The Performer HCP requests more information from the Requester HCP before they can decide whether to accept the referral. The Performer HCP and Requester HCP systems have the ability to communicate and send questions/additional information.

ii. Updates to the referral request (after step 5 and before Step 9)

The Performer HCP and/or Requester HCP may update the referral request after it is submitted to/ received by the Performer. This may include sending communications, updating the referral request with new information, etc.

iii. Case Assigner assigns the request to a Performer HCP (after step 6 and before step 7)

Typically, when multiple providers work at the organization (e.g., specialist clinic, hospital), a Case Assigner will assign incoming requests to an individual Performer HCP associated with the organization. If a preferred Performer HCP is not listed on the referral request or is unable to accept the request (e.g., does not have capacity to accept new patients), the request may be assigned to an alternate provider at the organization.

iv. The appointment scheduled with the Provider HCP is changed (after step 8 and before step 9)

When the original appointment is rescheduled, the Performer HCP updates information in the Target system and an update is sent to the Source system. The appointment may be rescheduled due to patient preference and at the discretion of the Performer HCP.

UC-01: Alternate Flows

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

A. Request declined by Performer HCP (step 8)

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 automatically transmitted to the Source system.

B. Referral request changed to a Consult request by Performer HCP (step 8)

The Performer HCP decides to decline the referral request (e.g., does not schedule patient for an in-person appointment) but provides advice to the Requester HCP. If the Target System includes this functionality, the Performer HCP can convert the referral request to an eConsult. Alternatively, the Performer HCP may decline the referral request and ask the Requester HCP to create and send an eConsult request.

C. Referral request cancelled by Performer HCP (after Step 8 and before Step 9)

The Performer HCP cancels the referral request after accepting the patient. This can occur when the Performer HCP or patient decides to cancel the request after it has been initiated but before the referral/consult process is completed. Reasons can vary and may include patient preference, changes in medical status or administrative reasons. The Performer HCP updates the referral status in the Target system and an update is transmitted to the Source system.

D. Referral request revoked by the Requester HCP (after step 5 and before step 9)

The Requester HCP may revoke the referral request after it is submitted to the Performer HCP and before the appointment with the patient is completed. Reasons can vary and may include patient preference, reassessment of patient needs, changes in medical status and/or clinical judgment/diagnosis, transfer of care to another provider or facility, or administrative reasons. The Requester HCP updates the referral status is the Source system and an update is transmitted to the Target system.