Primary care provider refers patient to specialist including summary care record

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State: Draft


Perspective: A provider referring a patient to a specialist

Context: The referring provider has made the determination that it is clinically and legally appropriate to send a referral and summary of care to the specialist.

Story: The referring provider searches for a patient in the practice EHR and initiates a referral message. The referral reason is described in the message. In some cases the referral is directed to a specific specialist, and in other cases to a specialist practice. The referring provider attaches clinical documents as needed for reference, and then sends the referral.

The specialist sees the new referral in her local practice EHR. If this is a new patient for the practice, a new patient is created in the EHR. The core referral and the various documents are imported into the new patient's chart.



The Referring Provider and Specialist (or specialty practice)
The Referring Provider's EHR
The Specialist's EHR

There may be hidden actors, such as potential intervening HISPs between the Source and Destination.

Data Exchanged (This section is non-normative)

The transmitted data will vary; some examples are provided below:

  1. In the simplest case, only a textual description of the referral may be transmitted
  2. The minimal IFR case will consist of a textual referral description with an attached summary of care (CCD or CCR)
  3. The ideally structured case will consist of an structured referral message or document (e.g., HL7 V2.5.1 REF I12 message) and an IFR-compliant summary of care document (such as a C32 CCD or a CCR)
  4. Optional attachments to any of these cases may include PDFs, images of various types (jpg, tiff, DICOM), and Office documents, such as word processing documents and spreadsheets (e.g., containing glucose logs, seizure diaries and the like).

User Acceptance Tests