NHS North West Genomics
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Referral Outcome [PCC-57] (Future Use)

Referral Outcome [PCC-57] - the Referral Recipient sends the result of a Genetic Clinical Referral at the end of care, or of a laboratory order (Genomic Test Order) when the report is issued. It closes the loop. The example is for a laboratory order.

References

Interaction

sequenceDiagram
    participant RI as Referral Initiator
    participant RR as Referral Recipient<br/>(Clinical Genetics)
    RR -->> RR: End of care / discharge
    RR ->> RI: Referral Outcome<br/>OSU^O51 SC/CM + document<br/>Task completed + document
    RI -->> RR: Acknowledgement
    RI -->> RI: Import document, close referral
    opt Document Sharing
        RR ->> RR: Publish document (Health Data API / MHD)
    end
Actor Optionality
Referral Initiator R (receive)
Referral Recipient R (send)

Where the referral or order is managed by GOMS, the outcome is a Task update that the RIE receives via MNS, retrieves from GOMS and converts to OSU^O51 or the O51 FHIR Message - see Status Updates from GOMS via MNS. Task.output references the reports in the NHS England Unified Genomic Record (UGR); they are not carried in the message.

Content

The outcome is a status update and a clinical document.

Status Update

Data item HL7 v2 (OSU^O51) FHIR (Task)
Order control ORC-1 SC status completed
Referral ID ORC-2 basedOn.identifier, focus
Order status ORC-5 CM businessStatus completed
Referrer ORC-12 and ORC-21 - required in this guide requester (unchanged)
Document MDM^T02 or OBX ED / RP output - an external reference to the document; for a laboratory order, every report issued, in the NHS England Unified Genomic Record (UGR), with its Report Identifier (see Genomic Orders with Multiple Reports)

The referral ServiceRequest.status becomes completed.

Clinical Document

Care delivered Document Profile
Laboratory order Genomic test report Genomic Test Report - DiagnosticReport, HL7 v2 ORU_R01
Clinical genetics referral Consultation note (clinic letter), LOINC 11488-4 Composition - To confirm

Whatever the type, the document SHALL:

  • be linked to the referral by the workflow that carries it (Task.output, MDM^T02 TXA-14, DocumentReference.context.related);
  • identify the patient with the same identifier as the referral;
  • answer the referral question or report the test result - for a referral, give the plan of care, including any cascade (family) testing offered;
  • name the Referral Initiator as a recipient, and the patient's GP if different.

Genomic Orders with Multiple Reports

A single genomic laboratory order may result in more than one report, for example:

  • several tests on the same order (more than one OBR / Genomic Test Directory code);
  • staged testing, where a later test depends on an earlier result (e.g. R210.2 small panel followed by R210.6 MLPA);
  • work, subcontracted or reflex orders the laboratory creates to fulfil the order - see Original Order, Instance and Filler Orders;
  • preliminary reports followed by a final report.

Each report is sent as it is issued (ORU_R01 / DiagnosticReport), linked to the order by the Placer Order Number (ORC-2 / OBR-2, DiagnosticReport.basedOn). A report's own status (OBR-25 F, DiagnosticReport.status final) only says that report is final - it does not say the order is complete, because further reports may follow.

Hospitals need to know when the entire order is complete - for example to close the order in the EPR, stop chasing outstanding results, and know that the set of reports they hold is the full answer to the request. This guide uses the order status update for that:

sequenceDiagram
    participant OP as Order Placer<br/>(Hospital EPR)
    participant OF as Order Filler<br/>(Genomic Laboratory)
    OF ->> OP: Report 1 - ORU_R01 / DiagnosticReport (final)
    OF -->> OP: Optional: OSU^O51 SC/A - Task in-progress
    OF ->> OP: Report 2 - ORU_R01 / DiagnosticReport (final)
    OF ->> OP: Order complete - OSU^O51 SC/CM<br/>Task completed, output = UGR references to all reports
    OP -->> OP: Close the order
Event HL7 v2 FHIR (Task)
A report is issued, more to follow ORU_R01; optionally OSU^O51 ORC-1 SC, ORC-5 A (some, but not all, results available) DiagnosticReport; Task.status in-progress, businessStatus interim-report - To confirm
The whole order is complete OSU^O51 ORC-1 SC, ORC-5 CM Task.status completed, businessStatus completed; Task.output references every report issued for the order - see Report References
  • The Order Filler SHALL send the order outcome (ORC-5 CM / Task completed) only once all reports for the order - including those from any filler orders - have been issued.
  • The Order Placer SHALL NOT treat a final report as completion of the order; it SHOULD use the order outcome to close the order.
  • An amended or corrected report issued after completion (OBR-25 C, DiagnosticReport.status amended / corrected) is sent as a further report; whether it also changes the order status is To confirm.
Report References

The O51 FHIR Message contains only the MessageHeader and the Task - the reports are not carried in it. Each Task.output (type reference-results) is an external reference to a report held nationally - a genomic test report DiagnosticReport in the NHS England Unified Genomic Record (UGR), or a document (e.g. a PDF report or consultation note) DocumentReference in the NHS England National Record Locator (NRL):

Task.output.valueReference Content
reference Absolute URL of the DiagnosticReport in the UGR or the DocumentReference in the NRL, where known - never a reference to a resource in the message or the sender's own repository. Omitted in the example, which references the report by its Report Identifier only
type DiagnosticReport (UGR) or DocumentReference (NRL)
identifier The Report Identifier (type FILL, assigned by the laboratory) - the same value as OBR-3 on the report's ORU_R01 and DiagnosticReport.identifier[ReportIdentifier]

The Report Identifier lets the Order Placer match each reference to a report it has already received (e.g. as ORU_R01), and retrieve any it has not from the UGR or NRL.

Where the order is managed by GOMS, MNS raises a genomic-order-event-1 for each DiagnosticReport and for the Task (and ServiceRequest) status change. The RIE converts report events to ORU_R01 (or the FHIR equivalent) and the order completion Task to OSU^O51 - see Status Updates from GOMS via MNS.

Example

The North West GLH has issued the report for Octavia CHISLETT's R240.1 order (ServiceRequest Coded Entries Example). It sends the outcome status update and the report (ORU_R01, Placer Order Number in ORC-2 / OBR-2).

MSH|^~\&|RIE|699X0|EPIC|R0A|20250220110000+0000||OSU^O51^OSU_O51|GLH-MSG-250220001|P|2.8|||AL|NE
PID|1||633^^^R0A^MR~9449305552^^^^NH||CHISLETT^Octavia||20080920|F|||1 RAVENSFIELD GARDENS^^EPSOM^SURREY^KT19 0ST
ORC|SC|1601737^R0A|R25012345^699X0||CM||||20250220110000+0000|||C3456789^Darwin^Samuel^^^Dr^^^GMC|||||||||MANCHESTER UNIVERSITY NHS FOUNDATION TRUST^^R0A^^^ODS

OSU^O51 has no segment for the reports. They are held in the UGR, and each is also sent separately as an ORU_R01 (Report Identifier in OBR-3) - see the HL7 v2 example instances.

FHIR Message: Bundle Message - Order Status (O51), outcome

  • the MessageHeader and the completed Task only. Task.output is an external reference to the genomic test report in the UGR, with its Report Identifier (25edee2b-add8-4522-9fa2-1ee8f229bd75, assigned by 699X0) - the same report as Diagnostic Report Example.

Expected Actions

  • The Referral Initiator SHALL store the document, make it available to users with access to the patient record, and show that the referral has ended.
  • It MAY import discrete data from the document or report (e.g. reportable variants).