Supporting Referrals to Diagnostic Services Published February 2017 NHS Digital is the trading name of the Health and Social Care Information Centre.
Contents Supported Referrals 3 Setting up a diagnostic service on the NHS e-referral Service 3 Determine which investigations are being provided by the service 4 Decide how these investigations will be grouped together as services 4 Map the service to a Specialty and Clinic Type in the NHS e-referral Service 4 Attach clinically appropriate SNOMED clinical terms to the service 4 Select the appropriate appointment type 5 Complete the Service Specific Booking Guidance 6 Complete Patient Instructions 6 Add links to Clinical Referral Templates and/or external guidance 6 Clinical Responsibilities Associated with Diagnostic Services 7 Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) 7 Direct or Indirect Booking for Diagnostic Services? 7 Integration with Radiology Information Systems 8 Appendix - Letter from Professor Erika Denton 9 NHS Digital is the trading name of the Health and Social Care Information Centre. 2
Supported Referrals NHS e-referral Service supports the following types of referrals for diagnostic tests: Specialty Clinic Types Diagnostic Imaging Bone Density Scan (DEXA) CT Fluoroscopy and Barium Studies Intravenous Urogram (IVU) MRI Nuclear Medicine Ultrasound X Ray Plain Film Diagnostic Endoscopy Colonic Imaging Assessment / Advice Flexible Sigmoidoscopy Gastroscopy Diagnostic Pathology Blood Test Diagnostic Physiological Measurement Aortic Aneurysm Assessment Audiology BP Monitoring Cardiac Test (Not Echo) Echocardiography EEG GI Physiology Nerve Conduction Studies Respiratory - Blood Gas Assessment Respiratory - Home Oxygen Respiratory - Lung Function Tests Respiratory - Sleep Apnoea Assessment Urodynamics Vascular Measurement and ABPI Setting up a diagnostic service on the NHS e- Referral Service The principles of setting up a diagnostic service are broadly the same as setting up any other service in the NHS e-referral Service; guidance is available on the the NHS e-referral Service website. There are several important points, however, which need particular consideration when setting up diagnostic services. NHS Digital is the trading name of the Health and Social Care Information Centre. 3
The following eight steps are involved: 1. Determine which investigations are being provided by the service 2. Decide how these investigations will be grouped together as services on the NHS e- Referral Service and select an appropriate and meaningful name for the service. 3. Map the service to a Specialty and Clinic Type in the NHS e-referral Service 4. Attach clinically appropriate SNOMED clinical terms 5. Select the appropriate appointment type 6. Complete the Service Specific Booking Guidance 7. Complete the Patient instructions 8. Add links to Clinical Referral Templates and/or external referral guidance (if applicable) Determine which investigations are being provided by the service A clinical decision needs to be made as to which tests or investigations a service will provide. These will need to be referenced by using appropriate SNOMED Terms. Decide how these investigations will be grouped together as services Individual tests/investigations provided within a single service should be sufficiently similar so as to ensure that the Patient Instructions and the Service Specific Booking Guidance, which apply to the whole service, are applicable to all of the individual tests covered by that service. It is important to note that if the guidance and instructions are not suitable or relevant for all tests provided, then separate services should be created within the NHS e- Referral Service, even if the patients are managed by the same teams or within the same diagnostic clinics. Map the service to a Specialty and Clinic Type in the NHS e- Referral Service Any service on the NHS e-referral Service needs to be mapped to both a Specialty and at least one Clinic Type. Not all providers will deliver services against every Clinic Type; therefore, only the relevant one(s) should be selected. Attach clinically appropriate SNOMED clinical terms to the service Diagnostic Clinic Types in the NHS e-referral Service have a predefined sub-set of SNOMED clinical terms associated with them which can be added as a default group. However, for diagnostic services that provide only a few very precise investigations, users may prefer to select those individual SNOMED clinical terms which most accurately describe the service being offered, adding these one by one. Since SNOMED terms are arranged in a hierarchical way, adding one term may bring in a sub-group of related terms. It is therefore vital to ensure that a clinical review of the service NHS Digital is the trading name of the Health and Social Care Information Centre. 4
takes place before it is published and that all the terms which are included are appropriate for the service. Those terms that are not should be deselected. As part of the service definition process, service providers may also wish to include nondiagnostic SNOMED clinical terms to help sign-post referrers to appropriate tests. For example, using the clinical term carpal tunnel syndrome should give the referrer the option of referring their patient to either an outpatient service such as Orthopaedics, or for a nerve conduction diagnostic test. Select the appropriate appointment type Appointments can be set up using either Diagnostic or First Outpatient appointment types: Diagnostic Appointment Type This should be thought of as the default appointment type for diagnostic services. It allows the service to be configured to support either a direct to test or a clinical assessment model. It is therefore important to consider how the service will operate: Direct to Test Model This allows the referral to be accepted straight into the service (or re- directed/rejected as necessary). For example a Bone Density Scan service would use the Diagnostic appointment type, with the Service Provider Clinician simply reviewing the clinical information (rather than clinically assessing the patient) before accepting, re-directing or rejecting the referral. To enable this option, Service Definers will need to select No for Supports Assessment/Onward Referrals option in the Assessment Capability Section of the Service Definition screen. If this is not done, the full two-stage assessment service functionality will be enabled, as detailed below Clinical Assessment Model There may be cases where a provider wishes to assess the referral before deciding on an appropriate test or other onward pathway. In such cases the refer on functionality, (usually associated with the Assessment Service appointment type), can be utilised within the Diagnostic appointment type. This will allow the service provider to review the request and refer the patient on to another service. For example, a request to a Colon Imaging Advice service may result in an onward referral to a Colonoscopy, CT Colonography, Barium Enema or a Flexible Sigmoidoscopy service. The assessment service model can also be used where the diagnostic test forms part of an assessment that will determine the onward referral pathway. In this case, the clinician, after carrying out the test, will decide with the patient what the most clinically appropriate onward pathway would be. For example, the result of a Urodynamics test carried out as part of a diagnostic assessment appointment, could determine an onward referral to either a Urology or a Gynaecology service (or the patient could be referred back to their referring clinician with the results of the test). In order to utilise the Referrals for Assessment worklist, Service Definers will need to select Yes for Supports Assessment/Onward Referrals option in the Assessment Capability Section of the Service Definition screen. First Outpatient Appointment Type This should be used for services led by a consultant, carried out in an outpatient setting. It may be that diagnostic tests are carried out as part of this appointment, but the referral is NHS Digital is the trading name of the Health and Social Care Information Centre. 5
essentially to a consultant-led outpatient service, not to a diagnostic service. For example, a referral to a First Outpatient Urology one-stop service may result in the patient having one of a number of diagnostic tests (e.g. urodynamics or ultrasound) as part of the initial consultation with the consultant. This type of service is already covered by the Choice Framework and the NHS Constitution, which allows patients in England to choose any clinically appropriate provider, and a named consultant-led team, for their first consultant-led outpatient appointment Complete the Service Specific Booking Guidance The Service Specific Booking Guidance contains important information, relevant to the individual service, which will be displayed to the referrer when they view the service details. There are three key areas which need to be completed: 1. Conditions treated 2. Procedures performed 3. Exclusions to the service It is important to ensure that these accurately reflect what the service provides, so that patients are seen in the most clinically appropriate service. Complete Patient Instructions Precise instructions for patients should be entered into the appropriate section of the service details. These will appear in the Appointment Details Letter (generated from within the NHS e-referral Service application) or in the Patient Web Application (where the appointment is booked on-line). In addition, they should be read out by a telephone operator, where the appointment is booked by phone. The wording of these instructions should be clear and informative to help ensure that the patient arrives fully prepared for the investigation. A web link to a patient information leaflet may also be included in this section, if required. Add links to Clinical Referral Templates and/or external guidance Providers of diagnostic services may wish to recommend that referrers use either nationally or locally agreed referral templates, or follow standard agreed guidance, to ensure that all the necessary clinical information is supplied and that the referral is appropriate. A set of Clinical Request Templates (CRT), agreed in 2007 as being suitable for use nationally, are available on the the NHS e-referral Service website. The CRTs can either be made available as a hyperlink from a provider s website, and added to the Administrative Requirements section of the service details, or converted to a suitable format and uploaded to individual referrer clinical systems to be completed by the referrer as a pre-populated template. The second method will reduce the amount of effort required by referrers in adding clinical referral information, but will require initial set-up time and resources in converting and uploading the templates. In a similar way, local guidance may be made available to referrers by adding a link to an external source, for example a provider trust s website, in the Administrative Requirements section of the Service Specific Booking Guidance. NHS Digital is the trading name of the Health and Social Care Information Centre. 6
Providers who add links (to forms or guidance) may also wish to consider using the Referrer Alert functionality to advise referrers of this. Clinical Responsibilities Associated with Diagnostic Services The service provider clinician always maintains responsibility for assessing the clinical appropriateness of any referral. This is particularly important for radiological referrals where adherence to IRMER (Ionising Radiation (Medical Exposure) Regulations) has to be considered. When the NHS e-referral Service is used to make a referral, the patient must book an appointment before the referral information can be viewed by the provider. However, the receiving clinician, who must justify the examination, always has the opportunity to re-direct or reject the referral, if it is clinically inappropriate. It is important that the patient is involved in any decision about changing their appointment, especially if this may be changing what was a diagnostic investigation to an outpatient appointment or if cancelling/re-booking the appointment for other reasons. Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) The Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER), require a referrer to be a registered health care professional who is responsible for providing sufficient information to enable the practitioner to justify the medical exposure. The regulations can be reviewed at following link: https://www.gov.uk/government/publications/the-ionisingradiation-medical-exposure-regulations-2000 When using the NHS e-referral Service for radiological referrals, a clinical referrer will have already been authenticated on the system via their Smartcard. This will enable the imaging service to verify that the referral is within the range of referral entitlement specified by the management responsible for the facility. A 2013 letter from Professor Erika Denton (National Clinical Director for Imaging) confirms that role-based access controls assigned to registered health care professionals serve as an alternative to the signature required on paper-based radiological referral forms. The letter is appended to this document, and refers to the NHS e-referral Service predecessor, Choose and Book. Direct or Indirect Booking for Diagnostic Services? Where diagnostic services (e.g. Diagnostic Physiological Measurement or Endoscopy services) are managed on a provider s Patient Administration System (PAS), they should be made directly bookable on the NHS e-referral Service, with all the associated benefits this brings. These benefits include: the certainty given to a patient of being booked straight into an appointment slot reduced administrative overhead for the providers the visibility for referrers of where their patients are in their treatment pathway NHS Digital is the trading name of the Health and Social Care Information Centre. 7
Integration with Radiology Information Systems Many radiological diagnostic services are managed through a Radiology Information System (RIS) and, as yet, these systems are not compliant with the NHS e-referral Service. While the NHS e-referral Service team continue to explore ways in which future RIS integration may be possible, such services will need to be set up as Indirectly Bookable on the NHS e- Referral Service. This will require the provider of the service to enter the relevant contact details into the Directory of Services, so that patients are guided to call the booking office to arrange their diagnostic appointment. NHS Digital is the trading name of the Health and Social Care Information Centre. 8
Appendix - Letter from Professor Erika Denton NHS Digital is the trading name of the Health and Social Care Information Centre. 9