Table of Contents

Abstract

Provides implementation of electronic referral messages using the HL7 Version 2.3.1 protocol with local extensions, which will be proposed for inclusion in a later version of HL7 2.x.

Scope

1.1 General
Health Level Seven (HL7) is a comprehensive health care communications protocol accredited as a Standard by the American National Standards Institute (ANSI). This Standard covers implementation of electronic referral messages using the HL7 Version 2.3.1 protocol with local extensions, which will be proposed for inclusion in a later version of HL7 2.x. It covers communication between health service providers both within and outside hospitals. The Standard includes the data segments and data elements that are mandatory (required), optional or conditional (required, based on a condition), and relevant usage notes in the Australian health environment. The Standard provides consistent use of data definitions as well as commentary and references to the International Organization for Standardization (ISO), the National Health Data Dictionary (NHDD), the National Association of Testing Authorities Australia (NATA), The General Practice Computing Group (GPCG) and its General Practice Data Model and Core Dataset (co-sponsored with the Commonwealth Department of Health and Ageing).
This Standard is for the purpose of sharing and transferring patient care. Its content is clinical. There are administrative, financial, and eligibility aspects of referral, which are representable in standardized HL7 segments. These are not included in this Standard.
The message structure described here is intended to communicate information representing a complete or partial transfer of care from one clinical provider or organization to another, occurring on discharge from a hospital or other care provider. It differs from a discharge summary although it may include such information or document. Relevant definitions are included in Clause 4 of this Standard.
Clinical management by cooperating providers, mandates health service messaging built on agreed semantic exchange. The above groups are actively participating in developments in this evolving area. While the message protocols described in this implementation Standard employ a required level of coding as in the HL7 tables, they do not specify any particular controlled vocabulary for the broader area of clinical concept representation. A logical next step in terminology agreement should address the headings used in referral, and a code set such as LOINC should be considered for this.
The HL7 messages detailed here have the capability but not the requirement of exchanging clinical data, and the segments have the capacity to include flexible structures containing both coded and free-form representations. This Standard is applicable across clinical domains, and is intended to be used for communication between providers and organizations with different information models and datasets. This will present a challenge to the exchange of structured clinical information, which will be required for a richer utilization of health information. Such a level of semantic exchange will enable processing aimed at supporting clinical decision making for optimal health outcomes. It is for this purpose that the referral message has been designed to optionally include segments covering the more complex clinical situations reflected in Problems, Goals, and Pathways. It is not however dependent on standardized clinical datasets, and is therefore immediately applicable.
1.2 Breadth of health record information content
This message is a general clinical communication, which carries health record information, including past history, family history, allergies, medications and medication history, social status, problem, goal and other management details as well as the requested services, which constitute the reason for referral.
Referral involves the transfer of care in part (e.g. request for an opinion or a specialized service accompanied by relevant health event summary and record extracts) or in whole (e.g. transfer from one GP practice to another with complete health record data and summary).

General Product Information

Published
Document Type	Standard
Status	Current
Publisher	Standards Australia
Pages
ISBN
Committee	IT-014
Under Revision	DR 05431
Supersedes	DR 02280