Bidirectional Services eReferral (BSeR), published by HL7 Public Health Working Group. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/bser/ and changes regularly. See the Directory of published versions

Transactions

Transaction Types

This specification defines two primary transaction types, the “Referral Request” and the “Referral Feedback”. For each "Referral Request" there may be multiple “Feedback” transactions which can be either technical or programmatic. Additionally, depending on the transaction paradigm, such as "Referral – Push" or "Referral – Notify and Pull," there may be a need for subcomponent transactions.

A referral request flows from a referral initiator to a referral recipient. The referral request transaction is comprised of the referral service request and its supporting information bundles and clinical statements. At times there may be an intermediary, such as a Community Based Organization (CBO) hub or a Health Information Exchange (HIE), between the referral initiator and the referral recipient.

A service request feedback transaction flows from the referral recipient to the referral initiator. The service request feedback transaction is comprised of the referral feedback document containing the referral activity status, supporting information bundles and clinical statements. At times there may be an intermediary between the referral recipient and the referral initiator.

Information Exchange

The exchange of information between a referral service request initiator and a referral service request recipient is bi-directional.

High-Level Referral Use Cases

This guide describes two high-level use cases which provide a general overview of the interactions and main actors involved, along with the major actions that occur within the context of the use case. These use cases do not delve into specific details or technical intricacies; instead, they serve as a conceptual representation of purpose and functionality.

Actors

• Patient
• Referral Initiator: Healthcare Provider
• Referral Recipient: Community Based Organization (CBO), Healthcare Organization (HCO), Healthcare Provider
• Intermediary: CBO Hub, Healthcare Information Exchange (HIE)
• Requirements Repository: Repository containing payload data element requirements (batch queries)

Referral Interaction Diagrams

Referral - Push

Referral Interaction Diagram Steps

Referral - Push Diagram Steps

Category	Step	Actor(s)	Description	Resources (where applicable)
Setup Coordination	Policy Agreements	Referral Initiator, Referral Recipient	The Referral Initiator and Referral Recipient negotiate required policy agreements
Setup Coordination	Addressing or Subscription Setup	Referral Initiator, Referral Recipient	The Referral Initiator and the Referral Recipient setup addressing and/or subscription requirements
Referral	Retrieve Clinical Payload Data Requirements	Referral Initiator	Referral Initiator queries the Requirements Repository for the referral request payload data requirements specific to the use case	BSeR Bundle Batch Query Referral Supporting Information
Referral	Query for Clinical Data Payload	Referral Initiator	Referral Initiator queries for the referral request resources specified in the payload data element requirements	Various use case specific clinical resources
Referral	Referral - Submit (Option A)	Referral Initiator	Referral Initiator submits the Message Bundle containing all the resources needed for the referral (MessageHeader, Task, ServiceRequest, all use case specific clinical resources) to the Referral Recipient	BSeR Referral Message Bundle, BSeR Referral messageHeader, BSeR Task, BSeR ServiceRequest,BSeR Coverage,BSeR Patient Consent, BSeR Referral Request Document Bundle, BSeR Referral Request Composition including various use case specific clinical resources
Referral	Referral - Subscription (Option B)	Referral Initiator	Referral Initiator (FHIR Server) automatically sends Subscription Notification to Referral Recipient	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Evaluation	Referral Recipient	Referral Recipient evaluates whether or not to accept the referral
Referral	Retrieve Response Payload Data Requirements	Referral Recipient	Referral Recipient queries the Requirements Repository for the referral feedback payload data requirements specific to the use case	BSeR Bundle Batch Query Referral Supporting Information
Referral	Referral Response(s) - Submit (Option A)	Referral Recipient	Once the requested service(s) have been performed the Referral Recipient submits the updated Task containing a Document Bundle with the use case specific referral feedback resources specified in the payload data element requirements	BSeR Task, BSeR Referral Feedback Document Bundle
Referral	Referral Response(s) - Subscription (Option B)	Referral Recipient	Once the requested service(s) have been performed the Referral Recipient (FHIR Server) automatically sends Subscription Notification (including Task) to Referral Initiator	R4 Topic-Based Subscription Notification Bundle, BSeR Task

Referral - Notify and Pull

Referral - Notify and Pull Diagram Steps

Category	Step	Actor(s)	Description	Resources (where applicable)
Setup Coordination	Policy Agreements	Referral Initiator, Referral Recipient	The Referral Initiator and Referral Recipient negotiate required policy agreements
Setup Coordination	Addressing or Subscription Setup	Referral Initiator, Referral Recipient	The Referral Initiator and the Referral Recipient setup addressing and/or subscription requirements
Referral	Notify of Referral - Submit (Option A)	Referral Initiator	Referral Initiator submits the notification (Task) of the Referral to the Referral Recipient	BSeR Task
Referral	Notify of Referral - Subscription (Option B)	Referral Initiator	Referral Initiator (FHIR Server) automatically sends Subscription Notification (including Task) to Referral Recipient	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Evaluation	Referral Recipient	Referral Recipient evaluates whether or not to accept the referral
Referral	Referral Response(s) - Submit (Option A)	Referral Recipient	Referral Recipient submits the updated Task with an accept/decline/etc.	BSeR Task
Referral	Referral Response(s) - Subscription (Option B)	Referral Recipient	Referral Recipient (FHIR Server) automatically sends Subscription Notification (including updated Task with an accept/decline/etc.) to Referral Initiator	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Retrieve Clinical Payload Data Requirements	Referral Recipient	Referral Recipient queries the Requirements Repository for the payload data requirements specific to the referral use case	BSeR Bundle Batch Query Referral Supporting Information
Referral	Retrieve Service Request and Clinical Payload Data	Referral Recipient	Referral Recipient queries the Referral Initiator and receives the ServiceRequest and referenced resources, and the referral request resources specified in the payload data element requirements	BSeR ServiceRequest,BSeR Coverage,BSeR Patient Consent, various use case specific clinical resources
Referral	Referral Response(s) - Submit (Option A)	Referral Recipient	Once the requested service(s) have been performed the Referral Recipient submits the updated Task containing a Document Bundle with the use case specific referral feedback resources specified in the payload data element requirements	BSeR Task, BSeR Referral Feedback Document Bundle
Referral	Referral Response(s) - Subscription (Option B)	Referral Recipient	Once the requested service(s) have been performed the Referral Recipient (FHIR Server) automatically sends Subscription Notification (including Task) to Referral Initiator	R4 Topic-Based Subscription Notification Bundle, BSeR Task

Referral - Push (with intermediary)

Referral - Push (with intermediary) Diagram Steps

Category	Step	Actor(s)	Description	Resources (where applicable)
Setup Coordination	Policy Agreements	Referral Initiator, Referral Recipient	The Referral Initiator and Referral Recipient negotiate all required policy agreements
Setup Coordination	Addressing or Subscription Setup	Referral Initiator, Referral Recipient	The Referral Initiator and the Referral Recipient setup all addressing and/or subscription requirements
Setup Coordination	Policy Agreements	Intermediary, Referral Recipient	The Intermediary and Referral Recipient negotiate required policy agreements
Setup Coordination	Addressing or Subscription Setup	Intermediary, Referral Recipient	The Referral Initiator and the Intermediary setup addressing and/or subscription requirements
Referral	Retrieve Clinical Payload Data Requirements	Referral Initiator	Referral Initiator queries the Requirements Repository for the referral request payload data requirements specific to the use case	BSeR Bundle Batch Query Referral Supporting Information
Referral	Query for Clinical Data Payload	Referral Initiator	Referral Initiator queries for the referral request resources specified in the payload data element requirements	Various use case specific clinical resources
Referral	Referral - Submit (Option A)	Referral Initiator	Referral Initiator submits the Message Bundle containing all the resources needed for the referral (MessageHeader, Task, ServiceRequest, all use case specific clinical resources) to the Intermediary	BSeR Referral Message Bundle, BSeR Referral messageHeader, BSeR Task, BSeR ServiceRequest,BSeR Coverage,BSeR Patient Consent, BSeR Referral Request Document Bundle, BSeR Referral Request Composition including various use case specific clinical resources
Referral	Referral - Subscription (Option B)	Referral Initiator	Referral Initiator (FHIR Server) automatically sends Subscription Notification to Intermediary	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Evaluation	Intermediary	Intermediary evaluates whether or not to accept the referral
Referral	Referral - Submit (Option A)	Intermediary	Intermediary submits the Message Bundle containing all the resources needed for the referral (MessageHeader, Task, ServiceRequest, all use case specific clinical resources) to the Referral Recipient	BSeR Referral Message Bundle, BSeR Referral messageHeader, BSeR Task, BSeR ServiceRequest,BSeR Coverage,BSeR Patient Consent, BSeR Referral Request Document Bundle, BSeR Referral Request Composition including various use case specific clinical resources
Referral	Referral - Subscription (Option B)	Intermediary	Intermediary (FHIR Server) automatically sends Subscription Notification to Referral Recipient	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Evaluation	Referral Recipient	Referral Recipient evaluates whether or not to accept the referral
Referral	Retrieve Response Payload Data Requirements	Referral Recipient	Referral Recipient queries the Requirements Repository for the referral feedback payload data requirements specific to the use case	BSeR Bundle Batch Query Referral Supporting Information
Referral	Referral Response(s) - Submit (Option A)	Referral Recipient	Once the requested service(s) have been performed the Referral Recipient submits the updated Task containing a Document Bundle with the use case specific referral feedback resources specified in the payload data element requirements to the Intermediary	BSeR Task, BSeR Referral Feedback Document Bundle
Referral	Referral Response(s) - Subscription (Option B)	Referral Recipient	Once the requested service(s) have been performed the Referral Recipient (FHIR Server) automatically sends Subscription Notification (including Task) to the Intermediary	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Referral Response(s) - Submit (Option A)	Intermediary	On receipt of submit from the Referral Recipient the Intermediary submits the updated Task containing a Document Bundle with the use case specific referral feedback resources specified in the payload data element requirements to the Referral Initiator	BSeR Task, BSeR Referral Feedback Document Bundle
Referral	Referral Response(s) - Subscription (Option B)	Intermediary	On Subscription Notification from the Referral Recipient the Intermediary (FHIR Server) automatically sends Subscription Notification (including Task) to Referral Initiator	R4 Topic-Based Subscription Notification Bundle, BSeR Task

Referral - Notify and Pull (with intermediary)

Referral - Notify and Pull (with intermediary) Diagram Steps

Category	Step	Actor(s)	Description	Resources (where applicable)
Setup Coordination	Policy Agreements	Referral Initiator, Intermediary	The Referral Initiator and Intermediary negotiate required policy agreements
Setup Coordination	Addressing or Subscription Setup	Referral Initiator, Intermediary	The Referral Initiator and the Intermediary setup addressing and/or subscription requirements
Setup Coordination	Policy Agreements	Intermediary, Referral Recipient	The Intermediary and Referral Recipient negotiate required policy agreements
Setup Coordination	Addressing or Subscription Setup	Intermediary, Referral Recipient	The Referral Initiator and the Intermediary setup addressing and/or subscription requirements
Referral	Notify of Referral - Submit (Option A)	Referral Initiator	Referral Initiator submits the notification (Task) of the Referral to the Intermediary	BSeR Task
Referral	Notify of Referral - Subscription (Option B)	Referral Initiator	Referral Initiator (FHIR Server) automatically sends Subscription Notification (including Task) to Intermediary	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Evaluation	Intermediary	Intermediary evaluates whether or not to accept the referral
Referral	Notify of Referral - Submit (Option A)	Intermediary	Intermediary submits the notification (Task) of the Referral to the Referral Recipient
Referral	Notify of Referral - Subscription (Option B)	Intermediary	Intermediary (FHIR Server) automatically sends Subscription Notification (including Task) to Referral Recipient
Referral	Evaluation	Referral Recipient	Referral Recipient evaluates whether or not to accept the referral
Referral	Referral Response(s) - Submit (Option A)	Referral Recipient	Referral Recipient submits the updated Task with an accept/decline/etc.	BSeR Task
Referral	Referral Response(s) - Subscription (Option B)	Referral Recipient	Referral Recipient (FHIR Server) automatically sends Subscription Notification (including updated Task with an accept/decline/etc.) to Initiator	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Referral Response(s) - Submit (Option A)	Intermediary	Intermediary submits the updated Task with an accept/decline/etc.	BSeR Task
Referral	Referral Response(s) - Subscription (Option B)	Intermediary	Intermediary (FHIR Server) automatically sends Subscription Notification (including updated Task with an accept/decline/etc.) to Referral Initiator	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Retrieve Clinical Payload Data Requirements	Intermediary	Intermediary queries the Requirements Repository for the payload data requirements specific to the referral use case	BSeR Bundle Batch Query Referral Supporting Information
Referral	Retrieve Service Request and Clinical Payload Data	Intermediary	Intermediary queries the Referral Initiator and receives the ServiceRequest and associated resources, and the referral request resources specified in the payload data element requirements	BSeR ServiceRequest,BSeR Coverage,BSeR Patient Consent, various use case specific clinical resources
Referral	Clinical Payload - Submit (Option A)	Intermediary	Intermediary submits the ServiceRequest and associated resources, the referral request resources, and the batch query feedback requirements specified in the payload data element requirements to the Referral Recipient	BSeR Bundle Batch Query Referral Supporting Information,BSeR ServiceRequest,BSeR Coverage,BSeR Patient Consent, various use case specific clinical resources
Referral	Clinical Payload - Subscription (Option B)	Intermediary	Intermediary (FHIR Server) automatically sends Subscription Notification to Referral Recipient	R4 Topic-Based Subscription Notification Bundle
Referral	Referral Response(s) - Submit (Option A)	Referral Recipient	Once the requested service(s) have been performed the Referral Recipient submits the updated Task containing a Document Bundle with the use case specific referral feedback resources specified in the payload data element requirements to the Intermediary	BSeR Task, BSeR Referral Feedback Document Bundle
Referral	Referral Response(s) - Subscription (Option B)	Referral Recipient	Once the requested service(s) have been performed the Referral Recipient (FHIR Server) automatically sends Subscription Notification (including Task) to Intermediary	R4 Topic-Based Subscription Notification Bundle, BSeR Task
Referral	Referral Response(s) - Submit (Option A)	Intermediary	On receipt of submit from Referral Recipient the Intermediary submits the updated Task containing a Document Bundle with the use case specific referral feedback resources specified in the payload data element requirements to the Referral Initiator	BSeR Task, BSeR Referral Feedback Document Bundle
Referral	Referral Response(s) - Subscription (Option B)	Intermediary	On Subscription Notification from the Referral Recipient the Intermediary (FHIR Server) automatically sends Subscription Notification (including Task) to Referral Initiator	R4 Topic-Based Subscription Notification Bundle, BSeR Task