1. Use cases for referrals Many small healthcare providers, no central system Centrally assisted referrals Centrally semi-automated referral management Cross-community automated referral management

2. “Media” – Many small providers Example –Dentists Thousands of small practices One practice typically consults and refers with a few other small practices Very old referral system –Mail films and a letter Current practice –Email films and a letter (encrypted email)

3. Use Cases XDM Media Arrival Implies Request Request Description Is part of the media package Eliminate Data Entry No Central System No Request tracking Implementation plan: - Define a simple generic request description - Use XDM (email, CDROM, etc.) - Put request and supporting documents on the media - Specific disciplines may extend this with “uber-content-profiles” that specify discipline specific requirements on supporting documents Many small healthcare providers, no central system

4. Paper Slip – Centrally assisted Physician provides patient with a “ticket” and the patient makes referral selections. Example today –NHS “Book and Order” Physician gives the patient a referral description, a list of qualified providers, and a order number. The patient picks a provider based on location, schedule, convenience, etc. The patient provides the provider with the order number. The central system manages transfer of supporting documents to the provider, using the order number to track authorizations, duplicates, billing, etc.

5. Use Case XDM Media Arrival Implies Request Request Description Is part of the media package Eliminate Data Entry No Central System No Request tracking Paper Slip People Manage request Request Description is In XDS, Supporting documents Are in XDS Eliminate Data Entry, Lost media Requires XDS Does not specify request tracking Use the same referral Description document. Use XDS rather than Media Use folders rather than Media Specify a relationship Between paper slip and Folder UUID Centrally assisted referrals

6. XDS – Centrally automated Two categories of use –Direct referral (or “push”) Physician sends a referral request token electronically to a specific provider. Physician places the referral description plus supporting documentation in an XDS folder. –Indirect referral (or “pull”) Physician places the referral description plus supporting documentation in an XDS folder. Physician places the referral request token in a generic worklist queue. A provider takes the token from the queue to accept the referral. Selection of the provider is not specified by the protocol. –There is a referral tracking environment to check status. Enables the creation of a “dashboard” to monitor overall status. –Eliminates media and paper

7. Use Case XDM Media Arrival Implies Request Request Description Is part of the media package Eliminate Data Entry No Central System No Request tracking Paper Slip People Manage request Request Description is In XDS, Supporting documents Are in XDS Eliminate Data Entry, Lost media Requires XDS Does not specify request tracking Direct XDSIn-Direct XDS A Request token tracks the Request. Referral Request Description is the same Directly feeds Provider Scheduled Workflow Generic Worklist “Broker?manager” Provider “pulls” The token Uses the XDS folder to hold supporting Documents and Referral Description Enables system-wide tracking and monitoring Centrally semi-automated referral management

8. Cross Community Automation will be more complicated than the combined direct and in-direct XDS. –Policies are not coordinated –Procedures, codes, drugs, etc. are not coordinated –Laws may be inconsistent –We have no examples to study or analyze Today’s practice: Media solution is used fairly widely –MD Anderson, MGH Patient referral is directed and coordinated by fax, telephone, etc. Patient arrives with media (or media is sent in advance) Diagnosis and treatment are based on the supporting documents on the media PLAN: Defer this use case until we have experience with the simpler use cases. The IHE profiling for the media referral should improve current practice modestly.

9. Technical Assumptions We can define a simple generic referral description. –Discipline specific details (e.g., lab procedures and image references) will be in discipline specific extensions to the simple description –Generic processing will be able to ignore all extensions. (This means also, no error checking of extension content by the generic processing.) We can define a specific use of folders for use in referrals without interfering with other XDS uses of folders, especially locally invented uses for folders.