Draft statement of the problem and potential solutions (referencing May 18, 2021 HL7 FHIR Connectathon 27 Discussion in Clinical Reasoning):
Determining end-to-end evaluation of clinical referrals, I.e., sharing relevant information for a referral or transfer of care from one practitioner or organization to another. A referral may include a consultation or second opinion whether for short or longer-term management of one or more health issues or problems.
Consider use of Communication and/or CommunicationRequest
Some have considered using Communication as a method to evaluate a referral and its fulfillment. Communication-related FHIR Resources include:
CommunicationRequest requests a payload of information from one entity (sender) to another entity (receiver) listing specific examples:
- A computer-based decision-support system requesting a reminder or alert be delivered to a responsible provider
- A physician requesting notification from the nurse if a patient's temperature exceeds a value
- A monitoring system or a provider requesting a staff member or department to notify a public health agency of a patient presenting with a communicable disease reportable to the public health agency
- A computer-based decision-support system proposes to send educational material to a patient
- CommunicationRequest section 8.21.2 (Boundaries and Relationships), the resource excludes requests for referrals and requests for therapy or counseling which would be handled by theServiceRequest The performance of a CommunicationRequest may result in a Communication resource.
- ServiceRequest Section 12.14.2 (Boundaries and Relationships) states that ServiceRequest andCommunicationRequest are related. A CommunicationRequest is a request to merely disclose information. Whereas a ServiceRequest would be used to request information as part of training or counseling - i.e. when the process will involve verification of the patient's comprehension or an attempt to change the patient's mental state. In some workflows both may exist. For example, upon receiving a CommunicationRequest a practitioner might initiate a ServiceRequest.
Conclusion: ServiceRequest is the appropriate mechanism to reference a referral for consultation or transfer of service, and not CommunicationRequest or Communication
Use of ServiceRequest for referrals
FHIR v4.0.1: R4 combined the FHIR STU 3 ReferralRequest with other “requests” into a more comprehensive Resource called ServiceRequest that addresses diagnostic tests, procedures, therapies, counseling, specialist consultation and assessments, community services, and more. Such a ServiceRequest may be a higher-level authorization that triggers a Task to allow administrative actions such as keeping track of steps to be performed in fulfilling the ServiceRequest.
To address successful fulfillment of a referral for consultation, implementer feedback during the FHIR Connectathon 27 Clinical Reasoning Track indicated an effective approach:
- ServiceRequest for the initial referral
- Encounter to reference the fulfillment of the referral (basedOn the ServiceRequest)
- observation linked to the observation to the Encounter during which it occurred (encounter)
Consider use of Task
Might one also consider referencing Task.output as a way to link a Task to carry out a ServiceRequest for consultation to the Observation required to fulfill the successful performance of the consultation.
Managing “Curbside Consults”
Implementer feedback during HL7 FHIR Connectathon 27 Clinical Reasoning Track suggests that Communication may have value for managing informal requests for advice about patient care from one practitioner to another; this type of communication is often called “curbside consultation”. It does not involve a formal request for consultation and the communication is often based on limited information shared during the “conversation”.
- When managed using a secure organization-specific messaging service, the “curbside consult” may be modeled as initiating with a CommunicationRequest the results in several rounds of interactive responses. The implementer’s use case subsequently saved the “chat” to the patient’s record to save the discussion and also to protect the sender and receivers from potential liability by retaining what information was shared to generate the response received.
- From the standpoint of quality measurement and clinical decision support, the CommunicationRequest and Communication Resources may provide value for analyzing such “curbside consults”. However, based on feedback and the CommunicationRequest and Communication Resources should not be used for formal referral management.
 FHIR STU 3 ReferralRequest purpose was for sharing relevant information for a referral or transfer of care from one practitioner or organization to another. The intent was to address a requirement that another provider evaluate the patient for a consultation or second opinion whether for short or longer-term management of one or more health issues or problems.