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UC-02: Provider-to-Provider Consultation Request

UC-02: Description

Requester Health Care Provider (HCP) would like to seek advice/opinion from a specialist.

UC-02: Scenario

Note: In this example, the family doctor manages the eConsult directly in his POS system. The electronic medical record (EMR) solution (POS system) could be integrated with an external Referral Management System (RMS) or the EMR solution could have the capability to directly manage eConsults.

Jane Doe visits her family doctor complaining about pain occurring in her back and lower abdomen for the past two days. During the assessment, the family physician 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 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 finds an incidental complex renal cyst. Jane's family physician decides to consult a urologist to determine if the cyst can be managed with serial imaging, or whether a referral and consideration of a biopsy is necessary.

The consultation request is created and submitted to the specialist as follows:

Option 1 (UC-02a): Directly to a specific specialist

The eConsult request is sent directly to a designated specialist (individual).

The family physician creates the eConsult request and selects the desired urologist (e.g., one whom they have an existing professional relationship). The request is submitted directly to the selected urologist.

Option 2 (UC-02b) Directly to a specific organization

The eConsult request is sent to a designated organization (e.g., specialist clinic, hospital, etc.) that offers the required service. These organizations are staffed by multiple healthcare professionals (e.g., specialists) that offer the specialized care and/or services. Typically, a Case Assigner at the organization is responsible for assigning the request to an individual specialist within the organization.

The family physician creates the eConsult request and submits the request to the selected organization (e.g., specialist clinic or hospital). The request is received by the Case Assigner who assigns the case to an available urologist at the organization.

Option 3 (UC-02c) To Central Intake/Specialist Pool

When a central intake model/specialist pool is used for eConsults, Central Intake/Specialist Pool serves as a centralized mechanism to manage and distribute eConsult requests and facilities the response process. Upon receiving an eConsult request, Central Intake/Specialist Pool may triage the request based on urgency, clinical criteria, or specific protocols (e.g., jurisdictional/ regional clinical pathways and processes, designed with clinical experts). A Case Assigner at Central Intake/Specialist Pool may assign the request to an appropriate and available specialist within their network, or a specialist may self-assign requests.

The family physician creates an eConsult request and submits the request to Central Intake/ specialist pool (e.g., specialty service group, managed specialty). The Case Assigner at Central Intake assigns and forwards the request to an available urologist.

After Case Assignment

The urologist receives a notification of the assigned case, reviews the details, and sends a response back to Jane's family physician. Based on the size and characteristics of the cyst reported on the ultrasound, the specialist indicates that it can be safely monitored without the need for immediate intervention. A repeat ultrasound is recommended within 6 months. Jane's family physician receives the urologist’s response, reviews the notes and is satisfied with the response. Since no further clarification is required, the family physician closes the case.

UC-02: Participants

People	System
Requester Health Care Provider (HCP)	Source System (POS or RMS)
Performer HCP	Target System (POS or RMS)
Central Intake team/Case Assigner	Central System (RMS)

Please refer to Participants for definitions.

UC-02: Triggers

Requester Health Care Provider (HCP) seeks advice/opinion from a specialist on a patient case.

UC-02: Pre-conditions

• The Source system/Target system used by the healthcare provider is a) the point of Service (POS) system that includes RMS capability, or b) a standalone 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 Requester Source system has the ability to submit eConsults in the prescribed format.
• The Performer Target system has the ability to receive and respond to eConsults in the prescribed format.
• Patient information in Source system is valid.
• UC-02c only: The Performer HCP has registered as a service provider for centrally managed referrals.

UC-02: Post-conditions

• Primary Flow: The Requester HCP closes the consult request after receiving response from the Performer HCP (i.e., Requester HCP has no further questions);
• Alternate A: The Requester HCP revokes the consult request;
• Alternate B: The Requester HCP revokes the consult request and redirects the request to different specialist, organization or specialist pool;
• Alternate C: The Requester HCP creates an eReferral based on eConsult response;
• Alternate D: The Performer HCP declines the consult request;
• Alternate E: Alternate E: The Performer HCP returns the consult request to the Case Assigner (only applicable to UC-02b and UC-02c)
• Alternate F: The Case Assigner declined the consult request (only applicable to UC-02b and UC-02c)

UC-02: Workflow Diagram

The use case diagram represents the participants and their role in the end-to-end use case with a high-level view of the flow of information.

Please see Sequence Diagrams for UC-02: Consultation Request for a technical sequence diagram implementing this use case.

UC-02: Primary Flow

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

1. The Requester HCP initiates a consult request for the patient case.

2. The Requester HCP searches for and selects the desired service and service provider from the Health Service Directory.

   1. If the request is sent directly to a specific specialist, the service (specialty/ subspecialty) and desired specialist (individual) are selected.
   2. If the request is sent directly to a specific organization, the service (specialty/ subspecialty) and the desired organization (e.g., specialist clinic, hospital) are selected.
   3. If the request is sent to central intake/specialist pool, the service (specialty/ subspecialty) is selected. The system may automatically assign a specialist pool (e.g., based on geographic boundaries) and/or the Requester HCP may select a specialist pool (e.g., based on patient preferences).

3. The Requester HCP writes the consultation questions and attaches images/notes to support the consult request.

4. The Requester HCP submits the consult request to the selected Provider HCP. The Source system transmits the request to the Target system.

5. The Target system receives the request.

   1. If the request is sent directly to a specific specialist, the Target system automatically assigns the case to the Performer HCP (designated specialist).

   2. If the request is sent directly to a specific organization, the Case Assigner at the organization reviews the consult request and assigns the case to the Performer HCP (specific specialist within the organization). Note: The Performer HCP may also self-assign incoming consult requests.

   3. If the request is sent directly to Central Intake/Specialist Pool, the Case Assigner at Central Intake receives the consult request through the Central Intake system and assigns the case to an appropriate and available Performer HCP. The Central Intake System transmits (routes) the consult request to the Performer HCP system (Target system). Note: The Performer HCP may also self-assign incoming consult requests.

6. The Performer HCP receives a notification of the new consult request and reviews the details.

7. The Performer HCP accepts the request and provides their response by entering notes and/or attachments in the Target system.

8. The Performer HCP sends the consultation response back to the Requester HCP.

9. The Requester HCP receives a notification in the Source system that a response to the consult request has been provided and reviews the specialist’s response.

10. The Requester HCP is satisfied with the advice/opinion and the request is completed.

UC-02: 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 7) The Performer HCP requests more information from the Requester HCP before they provide a consult response. The Performer HCP and Requester HCP systems have the ability to communicate and send questions/additional information.

ii. The Requester HCP needs clarification after receiving response (after Step 9 and before step 10) The Requester HCP would like clarification (e.g., additional information) after the initial consult response has been received from the Performer HCP. Both the Requester HCP system and Provider HCP system have the capability to send/respond communications (e.g., follow-up questions).

iii. The Performer HCP completes Performance KPI Survey (after step 10) The Performer HCP may answer questions related to billing and time spent on case after providing the consult. This may be a requirement in some jurisdictions.

iv. The Requester HCP completes Performance KPI Survey (after step 10) The Requester HCP may answer questions related to service utilization and feedback on the Performer HCP. This may be a requirement in some jurisdictions.

If a Case Assigner is involved (UC-02b and UC-02c)

v. The Case Assigner needs additional information (steps 5b/5c) The Case Assigner requests more information from the Requester HCP before they can assign the consult request. The Case Assigner and Requester HCP systems have the ability to communicate and send questions/additional information.

vi. The request is reassigned by the Case Assigner (after steps 5b/5c and before step 7) The Case Assigner may redirect the case to a different Performer HCP. Reasons for this can vary and may include case declined by Performer HCP, case revoked by the Case Assigner because the designated Performer HCP is unavailable or unable to provide a timely response. This does not close the consult request but rather redirects it to a new Performer HCP.

UC-02: Alternate Flows

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

A. Request cancelled by Requester HCP (after step 5 and before step 8) The Requester HCP decides to cancel the consult request before receiving a response from the Performer HCP. Reasons may vary and can include changes in patient’s medical status or administrative reasons that result in the consult no longer being required.

B. Request revoked by Requester HCP (after step 5 and before step 8) The Requester HCP revokes the consult request before receiving a response from the Perfomer HCP and redirects the request to a different specialist, organization or specialty group. The original consult request is closed, and a new request is created for the new Performer HCP.

C. Request results in an eReferral request (Step 7) The Performer HCP responds to the consult request and recommends the patient be evaluated by a specialist. The eConsult is completed and the Requester HCP initiates an eReferral. (see UC-01: Referral to a Service and UC-03 Referral to Central Intake). If the POS system/RMS includes this functionality, the Performer HCP or Requester HCP can convert the consult request to an eReferral.

D. Request declined by Performer HCP (Step 7) The Performer HCP declines/rejects the case because they are not able to provide advice/opinion. Reasons can vary and may include the specialist's capacity constraints/lack of availability, clinical appropriateness, missing information, or other constraints. This closes the consult request.

If a Case Assigner is involved (UC-02b and UC-02c)

E. Request returned to Case Assigner by Performer HCP (Step 7) The case is returned to the Case Assigner by the Performer HCP. Depending on the reason provided by the Performer HCP, the Case Assigner may then request additional information from the Requester HCP (additional flow v.), reassign the case to another Performer HCP (additional flow vi), or decline the request (alternate flow F.)

F. Request declined by Case Assigner (Step 5b/5c) The Case Assigner declines/rejects the consult because they are not able to assign the case to a Performer HCP. Reasons can vary and may include lack of specialist availability, clinical appropriateness, missing information, or other constraints.