Defines the Nexus EMR FHIR profile for referrals: a request that another clinician or service accept the patient, for consultation, second opinion, or ongoing management. Aligned to the pan-Canadian CA-eReC / Ontario eReferral contract, which is the shape Nexus already exchanges with Ocean. Distinct from NexusEmrCoreServiceRequest, which governs laboratory, imaging and procedure ORDERS and fixes intent to order.
Elements / Details
Every element this profile touches, with its full definition. Element names in the tables link here.
A referral: a request that another clinician or service accept the patient, for
consultation, second opinion, or short- or longer-term management.
The referrer does not control whether the receiving service accepts. That is why
intent is proposal and not order, and it is the substantive difference between
this profile and NexusEmrCoreServiceRequest.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
Comments
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
When the resource last changed - e.g. when the version changed.
Comments
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
Identifies EMR instance & pipeline version the resource came from
Definition
A URI that identifies the EMR pipeline and version from which this resource originated. This tells you which EMR instance (recommend using the instance identifier), and the version of the pipeline code/transformations.
Comments
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.
This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
Comments
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
Comments
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
A set of rules under which this content was created
Definition
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Comments
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Cardinality
0..1
Type
uri
Modifier
yes — This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Comments
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
A human-readable narrative summary of the referral for human interpretation.
Comments
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Comments
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality
0..*
Type
Extension
Modifier
yes — Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Unique identifiers for the referral.
A business identifier is recommended but not required (identifier is 0..*). Where
available, carry the source-system identifier using the most appropriate system URI. For
a referral received over Ontario eReferral this is the sending network's referral
reference, and preserving it is what lets a later status update or a returning consult
letter be matched to the referral it answers.
A source system's own identifier SHOULD be carried alongside this one, flagged use = secondary. See Carrying the raw code.
Comments
The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Requirements
Allows users to make use of identifiers when the identifier system is not known.
Comments
This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Requirements
There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Comments
If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
The URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest.
Comments
Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest.
Comments
This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
A shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier.
Requirements
Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes.
Comments
Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.
The state of the referral. draft written but not sent, active sent and awaiting the consult, on-hold waiting on something (imaging, bloodwork, patient contact), revoked declined or withdrawn, completed the consult happened.
Comments
This is a modifier element. A worklist showing what has been sent and not yet answered reads this element.
Cardinality
1..1
Type
code
Must Support
yes
Modifier
yes — This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Fixed to proposal: a referral asks a receiving service to accept the patient and carries no authorization to act. Matches CA-eReC and the Ontario eReferral profile.
Comments
A request the requester DOES have authority to have carried out is an order, not a referral, and belongs on NexusEmrCoreServiceRequest.
Cardinality
1..1
Type
code
Must Support
yes
Modifier
yes — This element changes the interpretation of all descriptive attributes. For example "the time the request is recommended to occur" vs. "the time the request is authorized to occur" or "who is recommended to perform the request" vs. "who is authorized to perform the request
The healthcare service or clinical specialty the referral is directed to. This is the
routing information: it is what decides which service receives the referral, so a wrong
value here sends the patient to the wrong place.
The binding is EXTENSIBLE, not required, and that is deliberate. Live Ontario traffic
includes concepts outside this value set -- Ocean sends 17561000 |Cardiologist|, an
OCCUPATION concept, where the value set carries services and specialties -- and a required
binding would make the referrals we actually receive non-conformant.
Preserve the raw coding exactly as received and add the Nexus coding alongside it in
the same element. Do not rewrite or drop the original: it is the evidence of what the
sending system meant, and normalising it away loses the only record of that.
Requirements
Used for filtering what service request are retrieved and displayed.
Comments
There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set.
How quickly the referral should be actioned. A referral worklist sorts on this: a suspected-cancer referral and a routine dermatology one do not wait in the same queue.
Set this to true if the record is saying that the service/procedure should NOT be performed.
Requirements
Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc.
Comments
In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.
Cardinality
0..1
Type
boolean
Modifier
yes — If true this element negates the specified action. For Example, instead of a request for a procedure, it is a request for the procedure to not occur.
Specific requested service, when more precise than category
Definition
The particular service, procedure or question being requested, when it is known and more
specific than category.
Optional: the Ontario eReferral contract carries the routing information in category and
sends no code. Where Nexus authors a referral itself, populate this from the reason for
referral so the receiving clinician can see what is being asked without opening the letter.
Where this code was mapped from a source system's own vocabulary, carry the raw coding alongside the mapped one, flagged userSelected = true. See Carrying the raw code.
Comments
Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code.
Additional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied.
Comments
For information from the medical record intended to support the delivery of the requested services, use the supportingInformation element.
An amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction).
Requirements
When ordering a service the number of service items may need to be specified separately from the the service item.
The clinician or organization making the referral. Required: a referral with no referrer cannot be answered, and loop closure has nothing to close against.
Comments
This not the dispatcher, but rather who is the authorizer. This element is not intended to handle delegation which would generally be managed through the Provenance resource.
Desired type of performer for doing the requested service.
Comments
This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”.
The service or clinician the referral is directed to
Definition
The receiving service, clinician or organization. Optional rather than CA-eReC's 1..*, because Nexus also records referrals that were never sent electronically and referrals whose destination is not yet chosen. Populate it whenever the destination is known.
Comments
If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B).
The clinical reason for the referral -- the question being asked of the receiving service. Where this code was mapped from a source system's own vocabulary, carry the raw coding alongside the mapped one, flagged userSelected = true. See Carrying the raw code.
Comments
This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use CodeableConcept.text element if the data is free (uncoded) text as shown in the CT Scan example.
Indicates another resource that provides a justification for why this service is being requested. May relate to the resources referred to in supportingInfo.
Comments
This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in DiagnosticReport.conclusion and/or DiagnosticReport.conclusionCode. When using a reference to DocumentReference, the target document should contain clear findings language providing the relevant reason for this service request. Use the CodeableConcept text element in ServiceRequest.reasonCode if the data is free (uncoded) text as shown in the CT Scan example.
One or more specimens that the laboratory procedure will use.
Comments
Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.
Anatomic location where the procedure should be performed. This is the target site.
Requirements
Knowing where the procedure is performed is important for tracking if multiple sites are possible.
Comments
Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure.
This might not include provenances for all versions of the request – only those deemed “relevant” or important.
This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude
All Provenances should have some historical version of this Request as their subject.