Primary care provider refers patient to hospital including summary care record

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State: Draft


Perspective: A primary care provider (PCP) referring a patient for inpatient care

Context: The PCP has made the determination that it is clinically and legally appropriate to send a referral and summary of care information to the hospital.

Story: The PCP searches for a patient in her EHR and initiates an order for inpatient care. She describes the order, including the hospital facility she is ordering service from. She attaches various documents for reference. She then sends the order.

The order is received by the hospital and triggers various workflows in the patient registration and hospital clinical systems to create the clinical order and associate it with the patient account and the schedule.



The PCP and Hospital
Various hospital systems (patient accounting, hospital clinical, scheduling)

There are potential hidden actors, such as the HISP for the Source and the hospital's HISP functions (which may be integrated with the hospital clinical system).

Data Exchanged (This section is non-normative)

The transmitted data in this case can and will vary, but some example cases are provided below:

  1. In the simplest case, only a textual description of the order may be transmitted.
    1. The textual description may be semi-structured as an MDM message
  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 order document or message (e.g., HL7 V2.5.1 ORM message), and information describing the patient accounting details (e.g., an ADT A14 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 will 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).

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