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S&I Framework
Transition of Care (ToC) Initiative
User Story
Closed Loop Referral
Origin PCP’s Office
Setting: PCP’s office
Activity: PCP Physician is in the middle of an encounter (office visit) with a patient and determines that
the patient needs to be referred to a specialist. The PCP is documenting the encounter in the EHR and
within the EHR prepares the consultation request message to the specialist. The message is addressed to
the appropriate specialist and is sent to the specialist’s EHR directly or via trusted intermediary.
A copy of consultation request message is sent directly or via trusted intermediary to the patient’s PHR.
Message Contents: Both minimal standard data set and referral context relevant data set
Message always includes standard minimal data set:
 Demographic information, active medication list (with doses and sig), allergy list, problem list,
reason for referral, etc.
Message contains variable data set relevant to the context of the request:
 Examples:
o Cover note describing the clinical impetus for the referral
o For a cardiologist consultation request: cardiology relevant tests and results such as
Cardiac Echo results, Holter Monitor results, etc.; cardiology pertinent family, social
histories, procedures, PE findings, etc..
o For a dermatologist consultation request: dermatology relevant tests and results such as
skin biopsy path report, image of lesion, dermatology pertinent family, social histories,
procedures, PE findings, etc..
o Specific example:
 PCP has worked up a patient who has a working diagnosis of Thyroid Cancer and
is referring the patient to an Endocrine Surgeon.
 Message includes standard minimal data set as above as well as the PCP
selected referral specific variable data set. E.g.:
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Pertinent PE finding and history of present illness: 3 month history of a 2 cm R
sided, hard thyroid nodule
Pertinent results and diagnosis: FNA done 2/28/11 significant for medullary
carcinoma, Calcitonin 2700, CEA 7, TSH, T3 Free T4 all normal
Pertinent Additional Diagnoses Medical /Surgical Hx: significant only for 3 year
history of mild obesity, current BMI 30
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Pertinent Family History: significant for Thyroid cancer mother (unknown type).
No history of MEN Syndromes. No History of radiation exposure.
PCP referral request and determination of responsibility: Please evaluate for
possible MEN II syndrome, surgery, post operative care, and any special
recommendations. I will assume full care status post the procedure.
Reference to shared information with Patient: I have reviewed all of the above
information with the patient and his wife.
Patient did/did not understand what was communicated
Message Transfer: From PCP to Specialist via Direct Messaging
Receipt in Specialty Office
Setting: Specialist’s office
Activity: Practice staff promotes the referral request to the specialist’s EHR document review task list.
In accordance with practice policies and workflow the specialist reviews the document and orders any
additional tests to be performed for the patient prior to the office visit. Discrete data elements from
within the message are promoted to the specialist’s EHR system date, time and source stamped.
When patient arrives at the specialist’s office he/she is registered in accordance with practice policies
and workflow. The specialist documents the encounter in the EHR and prepares the consult message to
the PCP. Once the message is prepared it is addressed and is sent directly or via trusted intermediary to
the PCP’s EHR. A copy of the message is retained in the specialist’s EHR.
Message Contents: Both minimal standard data set and referral context relevant data set
Message always includes standard minimal data set:
 Demographic information, specialist reconciled active medication list (with doses and sig),
allergy list, specialist reconciled problem list, specialist recommendations, etc.
Message contains variable data set relevant to the context of the referral:
 specialist recommendations, pertinent findings, test or study results, procedures or operations
and reports, indication of any specialty ongoing follow up responsibilities, what has been
communicated to the patient, patients level of understanding of what was communicated,
Receipt in PCP’s Office
Setting: PCP’s office
Activity: Message received into PCP practices’ EHR. Once the message is received into the EHR,
additional practice variable activities may occur: patient’s message can be directed to a front desk staff
HER work queue for appropriate distribution to additional staff EHR work queues as appropriate to the
practice workflows. For example, the front desk staff may schedule a follow-up visit with the patient
and add the patient’s consultation message to the PCP’s document task list. If the patient has an
assigned Care Manager that follows the patient at an advanced practice care facility (such as a PatientCentered Medical Home), the consultation message is directed to both the PCP and the Care Manager
for appropriate compliance planning. Discrete data elements from within the message can be promoted
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to the PCP’s EHR system date, time and source stamped. In accordance with practice policies and HER
functionality, the PCP can review and promote to the EHR the new reconciled active medication and
problem lists, any new procedures can be accepted into the EHR, and any other new discrete data
elements. The consultation message can be retained in its entirety as a permanent part of the patient’s
EHR record.
The patient comes for the encounter with the PCP and the PCP documents the encounter in the EHR.
Receipt in Patient’s PHR
Setting: Patient’s Home
Activity: Message received into Patient’s PHR via Messaging. Depending on the specific PHR, patient
may receive a notification to access their PHR as there is new information available. Patient (or patient’s
authorized proxy) can access the PHR and review the consultation request message. Patient (or their
proxy) may respond with confirmation or questions. Again, depending on the PHR’s functionality the
patient may be able to select sections with of the consultation request message (that are discrete data
elements) to automatically populate the appropriate fields in the PHR. For example, the patient can
upload any new problems to the problem list. Other PHR’s may have “all or none” functionality allowing
the patient to simply determine if they would like to retain to the PHR or delete from the PHR the
consultation request message.
Receipt in Patient’s PHR
Setting: Patient’s Home
Activity: Message received into Patient’s PHR. Depending on the specific PHR, patient may receive a
notification to access their PHR as there is new information available. Patient (or patient’s authorized
proxy) can log on to the PHR and review the specialist’s consultation message. Patient (or their proxy)
may respond with confirmation or questions. Again, depending on the PHR’s functionality the patient
may be able to select sections within the consultation request message (that are discrete data elements)
to automatically populate the appropriate fields in the PHR. For example, the patient can upload any
new problems to the problem list.