Referrals
Close the referral black hole. The Referrals module makes every specialist referral a trackable, bidirectional, standards-based exchange — from outbound creation with a USCDI v3 clinical bundle attached, through closed-loop status tracking (Sent → Received → Scheduled → Consult Complete), to the consult report arriving back in the chart automatically. An insurance-aware referral finder surfaces in-network specialists. Transport uses FHIR ServiceRequest over Direct Trust with TEFCA fallback. Because REV.health is the single platform spanning all of a patient's care relationships, every referral exchanged enriches the same global clinical record.
Key Capabilities
Referral Creation with Clinical Context
One screen. Under sixty seconds. The provider selects a patient, enters a reason, sets urgency (Routine / Urgent / Emergent), and picks a specialist from the directory. The system automatically assembles a USCDI v3 clinical bundle from the patient's global record — conditions, medications, allergies, lab results, imaging, immunizations, care plans, procedures, vital signs, and social history — and attaches it to the referral. The provider signs and sends. No fax machine, no missing context.
Specialist Search / Referral Finder
The specialist directory is populated from NPPES data, payer Provider Directory APIs, and per-practice manual curation. Each entry includes the specialist's NPI, Direct address, TEFCA endpoint URL, and insurance network affiliations. Insurance-aware routing filters the directory by the patient's active in-network plan from the Eligibility module — only in-network specialists are surfaced as recommended targets. Out-of-network options appear with a clear warning. When a referral requires prior authorization, the flag routes to Payer Optimization for concurrent PA processing.
FHIR ServiceRequest over Direct Trust
Outbound referrals are transmitted via Direct Trust to the specialist's
Direct address using FHIR ServiceRequest/Task resource payloads. When the
receiving specialist has no Direct address on file, the system falls back
to TEFCA-based exchange using the specialist's QHIN endpoint — the
referral is transmitted as a FHIR ServiceRequest bundle and
FhirServiceRequestID is stored for traceability. Both
channels are first-class; referrals are bidirectional by default.
Closed-Loop Status Tracking
Every referral follows a state machine with full audit:
Created → Sent → Acknowledged → Scheduled → Completed → Report Received.
Each transition automatically creates a ReferralStatusHistory
row recording the actor, timestamp, and new status. The referral
coordinator's worklist surfaces stalled items — referrals that haven't
been acknowledged within a configurable threshold trigger escalation
alerts. The loop is closed when the consult report arrives and is filed
back to the clinical record. A referral can be Cancelled from any
pre-completion state; once Report Received, the referral is closed-loop.
Follow-Up Request Routing
When the specialist responds to a referral — accept, decline, or request
modification — a ReferralResponse row is created with the
response type, narrative, and appointment date. Accept moves the referral
to Acknowledged; decline notifies the coordinator for rerouting; modify
routes back to the referring provider for review. Inbound responses are
auto-parsed from Direct Trust messages into structured fields — ≥ 90% of
inbound referrals auto-parsed with no re-keying. Consult reports flow
back through the same Direct Trust channel and are filed as clinical
notes in Clinical Documentation.
Persona Connections
- Doctor — Referral creator. Generates outbound referrals during the visit without breaking flow. Composes the referral, picks the specialist, signs, and sends in under 60 seconds. Wants the consult report to come back attached to the patient automatically.
- Nurse — Follow-up tracking. Lives in the referral worklist. Chases acknowledgements, tracks scheduling status, ensures reports come back. Processes coordinator queue items, updates referral status, and increments standing-referral visit counters. Cannot create or sign referrals — only track and update.
- Specialist — Receiver. Receives inbound referrals via Direct Trust or TEFCA, with USCDI bundle parsed into structured fields. Responds with accept/decline/modify, provides appointment date, and sends the consult report back through the same channel. No re-keying required.
Technical Highlights
- FHIR ServiceRequest bundle. Outbound referrals are encoded as FHIR ServiceRequest resources with USCDI v3 clinical data attached. The bundle includes conditions, medications, allergies, lab results, imaging, immunizations, care plans, procedures, vital signs, and social history — drawn from the patient's global record. The ServiceRequest resource carries the referral reason, urgency, and target specialist NPI.
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USCDI v3 attachment. The clinical bundle assembled at
referral-creation time is a USCDI v3 conformant snapshot of the
patient's global clinical facts. Clinical facts are global (carry
SourceOrganizationIDin audit); the bundle snapshot is org-scoped. The specialist receives a more complete clinical picture than any single practice could assemble. - Direct Trust transport. Outbound referrals are transmitted via a Direct Trust HISP (Kno2/Updox) as secure clinical documents with FHIR ServiceRequest payload. Delivery success target: ≥ 99.9% first-attempt. When the specialist has no Direct address, the system falls back to TEFCA QHIN sub-participant endpoint routing. Transport is BUY, not BUILD — REV.health does not operate its own HISP or QHIN.
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Task lifecycle. The referral state machine is modeled
as a FHIR Task resource lifecycle:
requested→in-progress→completed. Each state transition maps to the Referral module's internal statuses (Created, Sent, Acknowledged, Scheduled, Completed, Report Received). TheReferralStatusHistoryentity provides the immutable audit trail on every transition — insert-only, never updated or deleted. -
All five referral entities are org-scoped.
Referral,ReferralResponse,ReferralStatusHistory,SpecialistDirectory, andStandingReferralall carryOrganizationIDand enforce Cosmos partition-key isolation. Clinical facts referenced by USCDI bundles are global per the clinical-data-is-global pattern.
Delivery Phases
Referrals are managed by fax and phone call. The provider fills out a referral form, the coordinator faxes it to the specialist, and tracks status in a manual worklist. The Referral entity and ReferralStatusHistory audit trail ship for internal tracking. The SpecialistDirectory is populated from NPPES data with manual curation. Outbound creation captures referral reason, urgency, and target specialist — but transport is fax/phone. Inbound responses are re-keyed manually. Closed-loop tracking is aspirational; the state machine is documented but not automated.
Direct Trust transport is live via HISP integration (Kno2/Updox). Outbound referrals are sent as FHIR ServiceRequest payloads with USCDI v3 clinical bundles attached automatically. Inbound responses are auto-parsed into structured
ReferralResponse fields —
≥ 90% auto-parse with no re-keying. Closed-loop state machine is fully
automated: every transition creates a ReferralStatusHistory row. The
referral coordinator worklist surfaces stalled items with escalation
alerts. Insurance-aware routing filters the specialist directory by the
patient's active in-network plan. Patient-facing referral visibility
is available through the Patient Portal.
Standing referrals support chronic care (e.g., 12 PT visits over 6
months). Referral creation target: < 60 seconds from intent to send.
TEFCA-based referral exchange extends reach beyond Direct Trust coverage — when a specialist has no Direct address, the referral routes through the QHIN sub-participant endpoint. Referral analytics dashboard provides completion rates by specialty, average time-to-report, stalled-referral heat map, and top referring providers. Referral template library ships with pre-built templates by specialty. Multi-org referral aggregation — when a patient sees providers at multiple REV.health practices, the referral worklist aggregates across orgs into a single patient-wide view.
Success Metrics
- Outbound referral creation time: < 60 seconds median from "Refer" click to send.
- USCDI bundle completeness: ≥ 95% of outbound referrals carry a complete USCDI v3 bundle.
- Closed-loop completion rate: ≥ 80% reach Report Received within 60 days (vs. ~30% fax-based baseline).
- Stalled referral rate: < 5% stall in Sent status > 7 days without acknowledgement.
- Direct Trust delivery success: ≥ 99.9% first-attempt delivery.
- Patient portal referral view rate: ≥ 70% of patients view their referral status within 7 days.
- Inbound referral auto-parse rate: ≥ 90% of inbound referrals auto-parsed into structured fields with no re-keying.
Module Dependencies
- Upstream — Clinical Documentation provides the global clinical facts (conditions, meds, allergies, labs, imaging) that compose the USCDI v3 bundle. Inbound consult reports are filed back as clinical notes.
- Lateral — Eligibility provides the patient's active coverage for insurance-aware routing. Task Management receives stalled-referral alerts and inbound response notifications. Payer Optimization processes PA flags when a referral requires prior authorization.
- Downstream — Scheduling creates appointments when a referral is accepted and the specialist provides a date. Patient Portal surfaces referral status and consult reports to the patient.