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11.1.1 Patient referral and responses

When a patient is referred by one healthcare entity (e.g., a primary care provider) to another (e.g., a specialist or lab) or when a patient inquiry is made between two separate entities, little is known about the information each party requires to identify or codify the patient. The receiving entity may have no knowledge of the patient and may require a full set of demographics, subscriber and billing information, eligibility/coverage information, pre-authorization information, and/or clinical data to process the referral. If the receiving entity already has a record of the patient, the precise requirements for identifying that patient record will vary greatly from one entity to another. The existing record of a patient residing in the database of a specialist, a lab, or a hospital may require updating with more current information. In addition, providers receiving a referral often require detailed information about the provider making the referral, such as a physician's name and address.

For example, a primary care provider making a referral may need to obtain insurance information or pre-authorization from a payor prior to making a referral. Getting this information requires an inquiry and a response between the primary care provider and the payor. In addition, the primary care provider may request results from a lab to accompany the referral. Getting these results may require an inquiry and a response between the primary care provider and the lab. The information could then be incorporated into a referral sent from the primary care provider to the specialist. As the referral is processed, requested procedures are performed, the results are observed, and the relevant data must be returned to the primary care provider. Such a response may frequently take the form of multiple responses as results become available.

The message set that encompasses these transactions includes the referral (REF), requests for information (RQA, RQC, RQP, RQI) and the returned patient information (RCI, RCL, RPA, RPI, RPL, RRI). The referral message originates a transaction and a return patient information message concludes the transaction. At least one RPA/RPI is required to complete a patient referral or a patient request transaction, although multiple RPI messages may be returned in response to a single REF message. The segments used in the REF, RQA, RQI, RQP, RRI, RPH, RCI, RCL, RPA and RPI messages encompass information about patient, guarantor and next of kin demographics, eligibility/coverage information, accident, diagnosis, requested procedures, payor pre-authorization, notes, and referring and consulting provider data.

11.1.1.1 Patient referral

There are clear distinctions between a referral and an order. An order is almost always an intra-enterprise transaction and represents a request from a patient’s active provider to supporting providers for clearly defined services and/or results. While the supporting provider may exercise great discretion in the performance of an order, overall responsibility for the patient’s plan of treatment remains with the ordering provider. As such, the ordering provider retains significant control authority for the order and can, after the fact, cause the order to be canceled, reinstated, etc. Additionally, detailed results produced by the supporting provider are always reported back to the ordering provider, who remains ultimately responsible for evaluating their value and relevance. A referral, on the other hand, can be either an intra- or an inter-enterprise transaction and represents not only a request for additional provider support but also a transfer of a portion or all of the responsibility for the patient’s plan of treatment. Once the referral is made, the referring provider, during the transfer period, retains almost no control of any resulting actions. The referred-to provider becomes responsible for placing any additional orders and for evaluating the value and relevance of any results, which may or may not be automatically passed back to the referring provider. A referred-to provider may, in turn, also become a referring provider.

A referral message is used to support transactions related to the referral of a patient from one healthcare provider to another. This kind of message will be particularly useful from the perspective of a primary care provider referring a patient to a specialist. However, the application of the message should not be limited to this model. For example, a referral may be as simple as a physician sending a patient to another physician for a consultation or it may be as complex as a primary care provider sending a patient to a specialist for specific medical procedures to be performed and attaching the payor authorizations for those requested procedures as well as the relevant clinical information on the patient's case.

In a community model, stringent security requirements will need to be met when dealing with the release of clinical information. This message set facilitates the proper qualification of requests because the message packet will contain all the data required by any application in the community, including the necessary patient demographic information and the proper identification of the party requesting the information.

11.1.1.2 Responding to a patient referral

When a patient is referred by one provider to another or is pre-admitted, there is a great likelihood that subsequent transactions will take place between the initiating entity (the referring or admitting physician) and the responding entity (the specialist or hospital). The subsequent transactions might include a variety of queries, orders, etc. Within those subsequent transactions, there must be a way for the initiating system to refer to the patient. The "generic" patient information included in the original referral or the pre-admit Patient Identification (PID) segment may not be detailed enough to locate the patient in the responding facility's database, unless the responding facility has assigned a unique identifier to the new patient. Similarly, the responding system may not have record retrieval capabilities based on any of the unambiguous, facility-neutral data elements (like the Social Security Number) included in the original referral or pre-admit PID segment. This problem could result in the responding system associating subsequent orders or requests with the wrong patient. One solution to this potential problem is for the responding system to utilize the RRI message and return to the initiating system the unique internal identifier it assigns to the patient, and with which it will primarily (or even exclusively) refer to that patient in all subsequent update operations. However, the intent of the RRI message is that it will supply the originator of the referral type message with sufficient patient demographic and/or clinical information to properly process continued transactions.

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