Description (*Please confirm or update this field for the new USCDI version*)
Provider-authored request to another provider, specialist, or organization for care services.
Examples include but are not limited to referral orders to a wound care specialist, housing services, and skilled nursing facility.
Submitted By: Grace Glennon, on behalf of NCQA
/ NCQA
Data Element Information
Data Element Description
Provider-authored request to another provider, specialist, or organization for care services.
Examples include referral orders to a wound specialist or podiatrist.
Use Case Description(s)
Use Case Description
Referral orders represent another important type of order to support care coordination. Not all necessary medical services can be provided by a single provider, making referrals a necessary data point. Like other orders, referral orders are routinely captured and exchanged across care settings for routine care. These orders can be captured and exchanged via standard vocabulary (SNOMED).
In addition to being collected and exchanged as part of routine care for patients, quality measures currently utilize referral order information to assess appropriate care. NCQA continues to add follow-up components to many new and existing measures to assess for appropriate care following a significant medical finding; referral orders are one component to appropriate follow-up.
Estimate the breadth of applicability of the use case(s) for this data element
(Level 2) – Use cases apply to most care settings or specialties.
Referral orders are documented, utilized and exchanged across care settings including primary care, outpatient and acute care settings, and a necessary process step to receive certain types of care.
ONC Priority
Address behavioral health integration with primary care and other physical care
Mitigate health and health care inequities and disparities
Address the needs of underserved communities
Address public health interoperability needs of reporting, investigation, and emergency response
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s)
SNOMED CT
Additional Specifications
FHIR US Core (6.1.0, 7.0.0) ServiceRequest- must have a code defining what is being requested
Current Use
(Level 2) Captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer
Extent of exchange
(Level 2) Between more than two production EHRs or other HIT modules using available interoperability standards
Supporting Artifacts
Referrals are used in quality measures today, and used as part of routine care across almost all provider types.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code)
No restrictions.
Restrictions on Use (e.g. licensing, user fees)
No restrictions.
Privacy and Security Concerns
Exchange of patient health information should follow HIPPA Privacy Rules.
Estimate of Overall Burden
Given that USCDI already includes other orders elements, exchanged via the same structure as this orders element, implementation burden should be low.
Other Implementation Challenges
No other known implementation challenges.
ONC Evaluation Details Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1 Maturity - Current Standards
Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2 Maturity - Current Use
Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3 Maturity - Current Exchange
Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4 Use Case(s) - Breadth of Applicability
Level 2 - Use cases apply to most care settings or specialties.
Comment
Submitted byportmi3 on
Commenter: Michael Porter, Mport Media Group, Inc. (Discharge Bridge — care-transition orchestration).
We support USCDI v7 Referral Order, Referral Note, and Reason for Referral for hospital → SNF / post-acute exchange. Please keep SNF / post-acute explicitly in examples and vocabulary guidance.
We support Medication Order and Medication Administration for transition medication safety, and recommend leveling Level 0 Discharge medications (and Medication List Type as applicable) so implementers can exchange a reconciled active list at handoff distinct from open orders vs administration.
We support Encounter Disposition, Appointment, Healthcare Agent, and Discharge Summary Note for operational handoff / decision-maker / disposition context, mapping to these existing elements before inventing new definitions.
We recommend evaluating structured Prior Authorization Determination Status for inclusion or leveling (ONDEC or comment adjacent to Health Insurance Information / related coverage elements), because authorization fragmentation blocks timely acute→post-acute transitions and is relevant under CMS interoperability and prior-authorization directions that reference USCDI. Prefer placement under Health Insurance Information or Orders as ONC prefers — not a new data class.
Prefer mapping operational handoff needs to existing USCDI elements — Encounter Disposition, Discharge Summary Note, Healthcare Agent, Facility Information — and leveling Level 0 Discharge medications — before inventing new definitions.
This comment reflects an implementer perspective. It does not imply ONC endorsement and does not claim HIPAA or SOC 2 certification.
SNOMED International commends ONC for naming SNOMED CT as an applicable vocabulary standard for Referral Orders but we recommend that this be elevated to a required designation. SNOMED CT procedure hierarchy provides a comprehensive, nationally and internationally standardised vocabulary for referral and consultation coding including 307837007 |Referral to person (procedure)| and 306206005 |Referral to service (procedure)| and its descendants which enables consistent, computable referral documentation across care settings. NCQA's HEDIS quality measures already incorporate SNOMED CT-coded referral value sets, demonstrating validated real-world adoption at scale.
Reliance on local or proprietary referral codes which still remain prevalent in EHR implementations, creates barriers to the care coordination interoperability goals of the 21st Century Cures Act and ONC's TEFCA framework. SNOMED CT designation as a required standard for Referral Orders, consistent with its use in CMS Quality Payment Program (QPP) technical specifications, would drive convergence across implementations and eliminate the need for costly mapping between systems.
Recommendation: Add an additional element to USCDI v7 in the Orders data class for Referral Orders, defined as a provider-authored request to another provider, specialist, or organization for care services. Examples include referral orders to a wound specialist or podiatrist. (Vocabulary standards: SNOMED CT)
Rationale: Referral Orders are another important order data element to support care coordination and are already routinely exchanged. Inclusion in USCDI should also facilitate the ability to close the loop on referrals to ensure services requested are carried out, and care is provided, which is the critical step for high-quality, equitable care. NCQA continues to add follow-up components to many new and existing measures to assess for appropriate care following a significant medical finding; referral orders are one component to appropriate follow-up.
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Submitted by portmi3 on
Commenter: Michael Porter, Mport Media Group, Inc. (Discharge Bridge — care-transition orchestration).
We support USCDI v7 Referral Order, Referral Note, and Reason for Referral for hospital → SNF / post-acute exchange. Please keep SNF / post-acute explicitly in examples and vocabulary guidance.
We support Medication Order and Medication Administration for transition medication safety, and recommend leveling Level 0 Discharge medications (and Medication List Type as applicable) so implementers can exchange a reconciled active list at handoff distinct from open orders vs administration.
We support Encounter Disposition, Appointment, Healthcare Agent, and Discharge Summary Note for operational handoff / decision-maker / disposition context, mapping to these existing elements before inventing new definitions.
We recommend evaluating structured Prior Authorization Determination Status for inclusion or leveling (ONDEC or comment adjacent to Health Insurance Information / related coverage elements), because authorization fragmentation blocks timely acute→post-acute transitions and is relevant under CMS interoperability and prior-authorization directions that reference USCDI. Prefer placement under Health Insurance Information or Orders as ONC prefers — not a new data class.
Prefer mapping operational handoff needs to existing USCDI elements — Encounter Disposition, Discharge Summary Note, Healthcare Agent, Facility Information — and leveling Level 0 Discharge medications — before inventing new definitions.
This comment reflects an implementer perspective. It does not imply ONC endorsement and does not claim HIPAA or SOC 2 certification.