Background

Patients move between care settings and responsibility for them is handed over from one clinician to another. Transfer of care messaging ensures that the clinical context and information about the patient is transferred when this occurs.

To receive and process Transfer of Care FHIR documents, GP IT suppliers are expected to provide their practice solutions with a Generic FHIR Receiver (GFR) and Payload Processor (PP) capability. The GFR is a crucial common requirement across several current NHS Digital programmes.

The scope for Transfer of care currently covers:

• Inpatient and Day Case Discharge Summary Document – An ITK3 FHIR Document containing Transfer of Care information supporting inpatient and day case discharges typically between an acute hospital and GP practice.
• Emergency Care Discharge Summary Document – An ITK3 FHIR Document containing Transfer of Care information supporting a discharge typically between an emergency care department and a GP practice.
• Inpatient and Day Case Discharge Summary (Mental Health) Document – An ITK3 FHIR Document containing Transfer of Care information supporting a mental health adult discharge summary to a GP practice.
• Outpatient Clinic Letter Document – An ITK3 FHIR Document containing Transfer of Care information between the hospital clinic and the GP and other relevant parties following a consultation in a clinic.

The four defined Transfer of care messages uses the Messaging Exchange for Social Care and Health (MESH) service for transport and the Interoperability Toolkit (ITK) version 3.0 specification as the message distribution specification. 

Outline Plan

Once both EMIS and TPP achieve a Full Rollout Approval Development Milestone Achievement Certificate (FRA DevMAC) they will be expected to rapidly enable the receipt of Transfer of Care FHIR messages for their GP Practice customer base. As part of this work, NHS Digital will reconfigure MESH Mailboxes of EMIS GP Practices to receive and respond to ToC FHIR messages. TPP will also enable local switches to allow the Mental Health Discharge use case to flow into SystmOne.

To encourage uptake at the Hospital end, NHSX and the Professional Record Standards Body (PRSB) are engaged with DSAS to develop a National Data Standard for the Inpatient (Acute) Discharge. NHS England could adjust the wording of the NHS Standard Contract to reflect the readiness of GP Practices to receive ToC FHIR messages, and the need for secondary care to meet these requirements.

To bring on other GP Foundation IT suppliers, they will be expected to complete conformance certification as receivers of ToC FHIR messages, and once a First of Type Development Milestone Achievement Certificate (FoT DevMAC) is achieved, undertake a successful FoT before receiving FRA DevMAC. Dependent on the size of their GP Practice customer base, there may be a need to adjust the Deployment Verification Criteria for FoT.

Secondary Care organisations implementing ToC would be responsible for their own planning. However, they have the option of going through Conformance Certification with Solutions Assurance as a sender of ToC and of doing end-to-end testing in the Integration Testing (INT) environment with stood-up solutions from GP IT suppliers before going live.

Summary of Change

Transfer of Care is about standardisation of the correspondence elements. As this is an interoperability piece of work, both secondary care and primary care need to support the standardisation changes. These are as follows:

• CLINICAL CONTENT LAYER – PRSB headings/sections & subheadings/elements
• TERMINOLOGY LAYER – SNOMED-CT and dm+d
• TECHNOLOGY LAYER – FHIR (HL-7) as the structure for carrying information
• TRANSPORT LAYER – MESH for direct electronic transfer to GP IT foundation systems
• BUSINESS LAYER – ITK3 Response Codes fed back to the Hospital from the GP IT foundation system confirming message has been processed and is relevant.

Full Specification

The latest FHIR specifications for the Transfer of Care payload can be accessed at https://developer.nhs.uk/transfer-care-specification-versions/.   

Contextual detail and specifications pertaining to the MVP aspect of this work can be accessed via the Transfer of Care Payload V0.7 document below: 

The Transfer of Care FHIR messages will use the ITK3 (Interoperability Toolkit) specification available here https://developer.nhs.uk/interoperability-tool-kit-itk-specification-versions/.

Suppliers should also consider the advice for practices and practitioners given in the Good Practice Guidelines for GP Electronic Patient Records (chapters 8d and 10) in designing message handling services and workflows for processing Transfer of Care messages.

Assurance Approach

It is expected that Transfer of Care conformance requirements will be held within a single consolidated Supplier Requirements Assessment List. This list will take the form of a spreadsheet and the content will cover all programmes dependent on the GFR. (Macros within the spreadsheet will allow filtering of requirements by the programme.)

The requirement areas are expected to include the use of MESH (Client and Server), the ITK3 messaging distribution specification, Transfer of Care payload specification and for GP IT suppliers, the GFR requirements. The Supplier Requirements Assessment List is not a Target Operating Model, and therefore no checking of end-to-end system integration is expected.

NHS Digital has developed an ITK3 Test Harness which is available for testing purposes by implementers. The ITK Test Harness can operate in the mode of receiving primary care practice solution, and in the mode of a sending hospital system. The latter would be of most interest to GP IT providers wishing to receive messages into a prototype GFR. Further information on the Test Harness can be found at https://developer.nhs.uk/itk3-test-harness/. 

FHIR messages can be sent using MESH from sender to recipient as per the ITK3 specifications. To ensure that senders are clear on the successful receipt or otherwise of their messages, the ITK3 Test Harness produces standard acknowledgements, including those reporting failures of messages. The ITK3 full acknowledgement response pattern can be found at https://developer.nhs.uk/apis/itk3messagedistribution/explore_response_patterns_1.html.

A pack of Transfer of Care Test messages can be obtained from https://developer.nhs.uk/itk3-test-harness/itk3-test-harness-test-message-examples/

For further advice, access to testing resources, and support contact itkconformance@nhs.net

Capability Associations and Interop Dependencies

This section lists the Capabilities this Standard is associated with and any other Interoperability Standards which are needed to meet this Standard (subject to change or refinement)