This Standard covers implementation of electronic referral messages using the HL7 Version 2.5 (V2.5) protocol with local extensions, which will be proposed for inclusion in a later version of HL7 V2.x. It covers communication between health service providers both within and outside hospitals, including communication for shared care and on discharge, other event summaries and notifications to shared electronic health record and clinical decision support systems.This 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 and takes cognizance of definitions used by or in the International Organization for Standardization (ISO), the National Health Data Dictionary (NHDD), the National Association of Testing Authorities Australia, and The General Practice Computing Group and its General Practice Data Model and Core Dataset (co-sponsored with the Australian Department of Health and Ageing).This Standard deals with representation of clinical information for the purposes of sharing and transferring patient care. There may be additional administrative, financial, and eligibility aspects of referral, which are outside the scope of this Standard, and have been excluded.The message structure described in this Standard is intended to communicate information from one clinical provider or organization to another (potentially via a shared electronic health record), and should be used wherever there is a complete or partial transfer of care, as occurs on discharge from a hospital or other care provider. Where used for transfer of care, the message will typically contain referral details as well as a discharge or other event summary. Relevant definitions are included in Clause 4.Clinical management by cooperating providers mandates health service messaging built on agreed semantic exchange. While the message protocols described in this 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 SNOMED CT® or LOINC® should be considered for this.The HL7 messages detailed here have the capability for 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 include, optionally, 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.
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