New Section Proposal for HL7 EHR Functional Profile Release 2

New Section Proposal for HL7 EHR Functional Profile Release 2 Prepared by: Helen Stevens on behalf of the Ambulatory Oncology Functional Profile project Date: December 14th, 2009 – Draft #1

Introduction During the analysis on the Ambulatory Oncology Functional Profile it was identified that the existing HL7 Functional Model did not provide requirements for the EHR to receive an electronic referral request. This is a requirement for the oncology setting where a large percentage of patient’s are received through referrals from general practitioners.

This gap was discussed at the December 1st EHR Working Group conference call and Helen was asked to put together an initial proposal for this requirement for the December 15th conference call.

Following is a use-case showing the Ambulatory Oncology example of this requirement and the proposed sections to the EHR Functional Profile.

Notes:  After some discussion, it was determined that the best section in the Functional Model for this requirement to be added would be under the DC.1.1.3.1 (Capture Data and Documentation from External Clinical Sources) because the primary requirement is to support the receipt and capture of the e-Referral.  All the Conformance Criteria were listed as SHALL based on the Ambulatory Oncology requirements; however, this would be subject to discussion at the EHR WG for the Functional Model.

Discussion Questions: 1. Is DC.1.1.3.1 (Capture Data and Documentation from External Clinical Sources) the appropriate section for this requirement? 2. Can this be represented as a single requirement (as shown), or is it necessary to split into Direct Care and Supporting requirements? 3. Which criteria should be represented as SHALL, SHOULD or MAY – or as conditional? 4. Are there any criteria that are missing or need to be reworded to suit non-AmbulatoryOncology settings? Receive and Process Patient Referral Use Case Use case describes act of physician’s office receiving referral and processing it according to practice acceptance rules. Collect all necessary information required to create a new patient record and schedule the initial patient visit. STORYBOARD Patient has a diagnosis or suspected condition involving cancer or hematologic disorder. Referring physician writes request for oncology or hematology consult and sends to receiving physician’s office. Registrar receives referral, reviews patient information and a decision is made on whether patient is accepted. Acceptance of the referral can be based simply on the diagnosis of a suspected or known cancer or haematological condition; however receiving physicians may also require the ability to ensure adequate testing occurs before accepting the patient. In these cases the physician may request that prior to the acceptance of the referral the patient has undergone testing such as but not limited to a biopsy, blood work and/or diagnostic imaging. The received patient information is recorded, any additional lab and diagnostic imaging test results are captured and the initial visit is scheduled. ACTORS: Registrar, Referring Office, Referring Physician, Patient, (Legal Guardian), Physician BASIC FLOW OF EVENTS 1. Registrar receives referral information 2. Registrar determines that a minimum set of required information has been received 3. Registrar records and validates patient information 4. Registrar and clinical personnel review information for acceptance criteria 5. Registrar contacts Insurance company for coverage eligibility and details of coverage 6. Acceptance decision is made 7. Patient Record is established 8. Any Clinical information that is available is entered into the system 9. Appointment is scheduled 10. Registrar communicates that the record is ready for review by clinical staff ALTERNATE FLOW OF EVENTS 6. Referring physician’s office is contacted for notification of rejection POST-CONDITIONS 1. Referral has been accepted 2. New Patient Record has been established 3. Clinical and administrative information received with referral have been incorporated into the new Patient Record. Proposed Functional Profile Sections ID# Name Statement / Description AND Conformance Criteria

DC.1.1.3.1.3 F Capture Referral Statement: Enable the capture and processing of referrals from care providers or healthcare Request organizations, including clinical and administrative details of the referral, and consents and authorizations for disclosures as required.

Description: When a system receives a referral request the request must be validated against established criteria to determine if it meets the recipient’s requirements and is appropriate. Referrals may be received for patients who do not previously exist in the recipient system and the system must allow for the ability to triage the request and respond to the requestor. If appropriate the system should allow for the creation of a patient record including the capture of clinical and administrative information received with the referral request.

1. The system SHALL provide the ability to capture referral(s) from other care provider (s), whether internal or external to the organization. 2. The system SHALL provide the ability to electronically capture referral(s) from other care provider (s), whether internal or external to the organization. 3. The system SHALL conform to function IN.5.1 (Interchange Standards), to support the receipt of electronic referrals. 4. The system SHALL conform to function DC.1.1.3.1 (Capture Data and Documentation from External Clinical Sources) to support the capture of e-referral documents and data. 5. The system SHALL provide the ability to identify and present recommendations for potential matches between the patient identified in a received referral and existing patient’s in the system. 6. The system SHALL provide the ability to receive a referral for a patient that does not previously exist in the system. 7. The system SHALL provide the ability to define a minimum set of required administrative information that must be included in a referral to be accepted. 8. The system SHALL provide the ability to capture administrative details (such as insurance information, consents and authorizations for disclosure) as necessary from a received referral. 9. The system SHALL provide the ability to capture clinical details as necessary from a received referral. 10. The system SHALL provide the ability to present received referrals to a user for triage and approval. 11. The system SHALL conform to function S.3.3.2 (Eligibility Verification and Determination of Coverage) and display the results of electronic referral eligibility and health plan/payer checking. 12. The system SHALL provide the ability to define diagnosis based requirements for accepting a referral. 13. The system SHALL provide the ability to define clinical requirements for acceptance of a referral such as test results. 14. The system SHALL provide the ability for a user to create a patient record from information received in a referral. 15. The system SHALL provide the ability for a user to reject a referral request

16. The system SHALL provide the ability for a user to specify the reason for a referral rejection

17. The system shall provide the ability to communicate to the referring provider the acceptance or rejection of the referral request including the reasons provided for acceptance/rejection. 18. The system SHALL provide the ability to communicate to the referring provider to request additional information prior to accept/rejection of referral request. 19. If the Referral includes a transfer of care (complete or partial or temporary), THEN the system SHALL provide the ability to document transfer of care according to organizational policy, scope of practice, and jurisdictional law.