Referral Transmission & Tracking

Transmitting Referrals

Referrals need to be securely transmitted to receiving providers. This can be done using various methods depending on the technical capabilities of the receiving system.

The Communication resource is used to represent the transmission event, including details about the sender, recipient, and payload. For recipients without a FHIR API, a Bot can be used to generate and send a PDF of the referral information.

C-CDA Transitions of Care

For interoperability with external systems, referrals often need to be transmitted as C-CDA (Consolidated Clinical Document Architecture) documents. The Transitions of Care template is specifically designed for referral scenarios and includes structured sections for:

• Reason for referral
• Current medications
• Allergies and adverse reactions
• Problem list
• Relevant diagnostic results
• Care plan and instructions

See the C-CDA Transitions of Care documentation for implementation details on generating standards-compliant referral documents.

// Example of generating a C-CDA Transitions of Care document for a referral
const ccdaDocument = await medplum.generateCCDA({
  patient: patientReference,
  templateType: 'transitions-of-care',
  serviceRequest: serviceRequestReference,
  includeSection: [
    'reason-for-referral',
    'medications',
    'allergies',
    'problems',
    'results',
    'care-plan'
  ]
});

Essential Referral Data Requirements

Clinical Documentation Requirements

Successful referrals require comprehensive clinical documentation to ensure:

• Specialist acceptance: Clear justification for the referral
• Insurance authorization: Medical necessity documentation
• Reimbursement compliance: Proper diagnostic and procedural coding
• Continuity of care: Complete clinical context transfer

Core Data Elements

Category	Required Elements	FHIR Resources	Billing Impact
Patient Demographics	Name, DOB, MRN, Insurance ID	Patient	Required for claims processing
Clinical Justification	Primary/secondary diagnoses with ICD-10 codes	Condition	Medical necessity for authorization
Diagnostic Evidence	Lab results, imaging reports, diagnostic tests	Observation, DiagnosticReport	Supports medical necessity
Treatment History	Previous interventions, medications tried	MedicationRequest, Procedure	Demonstrates step therapy compliance
Current Medications	Active prescriptions with dosages	MedicationRequest	Drug interaction screening
Allergies & Intolerances	Known allergies and adverse reactions	AllergyIntolerance	Safety screening
Insurance Information	Coverage details, authorization requirements	Coverage	Claims processing and authorization

Tracking Referral Status

Once a referral has been sent, it's important to track its status through the entire lifecycle. The Task resource is ideal for this purpose, as it provides a standard way to represent workflow status.

Enhanced Status Tracking

The Task resource should include business-specific status information:

{
  "resourceType": "Task",
  "businessStatus": {
    "coding": [
      {
        "system": "http://example.org/referral-status",
        "code": "prior-auth-pending",
        "display": "Prior authorization pending"
      }
    ]
  },
  "statusReason": {
    "text": "Waiting for insurance authorization - submitted 2024-01-15"
  }
}

Diagnostic Report Transfer

When diagnostic reports are required for the referral, ensure proper linkage:

{
  "resourceType": "DiagnosticReport",
  "id": "ecg-report-for-referral",
  "status": "final",
  "category": [
    {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code": "CUS",
          "display": "Cardiology"
        }
      ]
    }
  ],
  "code": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "11524-6",
        "display": "EKG study"
      }
    ]
  },
  "basedOn": [
    {
      "reference": "ServiceRequest/cardiology-referral-example"
    }
  ],
  "presentedForm": [
    {
      "contentType": "application/pdf",
      "data": "JVBERi0xLjMKJcTl8uXrp...",
      "title": "ECG Report - John Smith"
    }
  ]
}

Specialist Response Integration

When a specialist responds to a referral, their response can be captured as a DocumentReference and linked to the original referral through the ServiceRequest. If the response results in an appointment, an Appointment resource can be created and linked to the referral.

Billing Code Integration

Specialist responses should include appropriate billing codes for services rendered:

{
  "resourceType": "Encounter",
  "id": "specialist-consultation",
  "status": "finished",
  "class": {
    "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
    "code": "AMB",
    "display": "ambulatory"
  },
  "type": [
    {
      "coding": [
        {
          "system": "http://www.ama-assn.org/go/cpt",
          "code": "99244",
          "display": "Office consultation for a new or established patient"
        }
      ]
    }
  ],
  "basedOn": [
    {
      "reference": "ServiceRequest/cardiology-referral-example"
    }
  ],
  "diagnosis": [
    {
      "condition": {
        "reference": "Condition/final-cardiac-diagnosis"
      },
      "use": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/diagnosis-role",
            "code": "AD",
            "display": "Admission diagnosis"
          }
        ]
      }
    }
  ]
}

Example Specialist Response

{
  "resourceType": "DocumentReference",
  "id": "specialist-response-example",
  "status": "current",
  "docStatus": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "11488-4",
        "display": "Consultation note"
      }
    ]
  },
  "subject": {
    "reference": "Patient/example-patient-id",
    "display": "John Smith"
  },
  "date": "2023-06-15T10:00:00Z",
  "author": [
    {
      "reference": "Practitioner/cardiologist-id",
      "display": "Dr. Helen Cardio"
    }
  ],
  "authenticator": {
    "reference": "Practitioner/cardiologist-id",
    "display": "Dr. Helen Cardio"
  },
  "content": [
    {
      "attachment": {
        "contentType": "application/pdf",
        "data": "JVBERi0xLjMKJcTl8uXrp...",
        "title": "Cardiology Consultation Report - John Smith",
        "creation": "2023-06-15T10:00:00Z"
      }
    }
  ],
  "context": {
    "related": [
      {
        "reference": "ServiceRequest/cardiology-referral-example"
      }
    ]
  }
}