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From referral to a confirmed appointment

A referral to a public hospital clinic, step by step. The systems by layer, the work today, the same work with one agent, and who runs it.

By Murali SidLinkedInPublished Updated

A GP sends a referral to a hospital clinic. It arrives by fax, secure message or e-referral form. The result should be a confirmed appointment, or a clear decline back to the GP. Today a referral clerk in the central referral hub carries the work. A clinician triages each referral. With an agent, the clerk's typing and chasing move to the agent. The clinician still triages, and the clerk still decides any doubt about who the patient is.

The systems involved

The referral touches these layers. The healthcare page shows the full hospital estate.

How it runs today

Swimlanes for the GP and patient, the referral clerk, the clinician, the booking clerk and the systems. Step 1: the referral clerk receives a fax, secure message or e-referral. Step 2: the clerk finds the patient in the patient administration system (PAS). Step 3: the clerk registers the referral. Step 4: the clerk checks it is complete. Step 5: the clerk chases missing items, and the GP's reply by fax goes back to step 1. Step 6: a clinician triages it. Step 7: the clerk keys in the triage result. Step 8: letters go to the patient and the GP. Step 9: the booking clerk phones the patient, books and sends an SMS reminder. Step 10: the data warehouse reports the waiting list. A blue box under each step names the system it uses.
Referral to appointment todayMost steps are keyed by hand. Missing information sends the referral round the loop again.Open image at full size ↗

Handoffs. The clerk hands to the clinician for triage, then gets it back. The referral hub hands to the clinic. The hospital writes to the GP to ask for information, to acknowledge, or to decline. The clinic books interpreters and patient transport.

Where reporting comes in. PAS data reaches the data warehouse every night. The measures are time to triage, the number waiting, and the share seen within the recommended time. Queensland publishes specialist outpatient performance by category. Category 1 should be seen within 30 days and Category 2 within 90 days. Category 3 should be seen within 365 days (Queensland Health, accessed 15 October 2026). New Zealand reports Elective Services Patient Flow Indicators to Health NZ. One counts referrals processed within 10 working days. These rules were not checked in this research.

Volumes and cycle time.

  • In May 2026, 362,886 people in Queensland were waiting for a first specialist appointment. That was 15 percent more than a year earlier (AMA Queensland, August 2026, citing Queensland Health).
  • AMA Queensland calls the people waiting to get onto the list a "hidden waiting list".
  • One ENT service at Logan gets about 700 referrals a month. Sorting them takes about 12 clinical hours (Metro South Health research abstract, undated).
  • Waikato dermatologists handled more than 8,000 e-referrals in 2023 (Health Research Council, 2024).
  • Receipt to triage takes a few working days, and longer when clinicians are busy (typical, unsourced).
  • No current figure was found for the share of referrals that still arrive by fax.

Pain points.

  • Fax and re-keying.
  • The same referral arrives twice, by two channels.
  • The wrong patient is matched, or a duplicate record is created.
  • Incomplete referrals bounce back and forth.
  • Triage backs up when consultants are in theatre or on leave.
  • The GP and the patient do not know the status.
  • Long waiters lose touch, and phone numbers go stale.
  • Referral criteria differ by state and by clinic.

How agents run it

One agent runs fixed steps. Model calls only read documents and draft messages. Fixed rules decide order, limits and status. The agent writes nothing to the PAS until a clinician has triaged.

Swimlanes for the agent, the referral clerk, the clinician, fixed rules, the systems and the evidence store. Step 1: the agent takes in the referral and opens a referral task. Step 2: it proposes the patient match, and the clerk confirms. Step 3: fixed rules check completeness, and the clinical lead approves the rules. Step 4: the agent asks the referrer for missing items, and the clerk approves. Step 5: it prepares the triage view. Step 6: a clinician triages, which is the clinical decision. Step 7: the agent adds the patient to the waiting list in the PAS, and the clerk approves. Step 8: it offers slots in a fixed booking order, and the clerk approves any exception. Step 9: it books and reads back the result. Step 10: waiting list reports run as today. The evidence store keeps traces, the PAS audit log, message logs and the original documents. A diamond marks each approval.
Referral to appointment with an agentA diamond marks each approval. Triage stays with the clinician.Open image at full size ↗

What stays with a person, and why.

  • The urgency category, and accepting or declining the referral. That is a clinical decision.
  • Any doubt about who the patient is. A wrong match exposes one patient's record to another.
  • Booking out of category order. That is a fairness decision about a person.
  • Declining a referral and telling the GP. It is a clinical decision and a legal record.
  • Using My Health Record. Access rules and the patient's own controls apply.

At Logan, a model called ReferralAI suggests an urgency category to clinicians. A suggestion model like this is a separate tool. It needs its own testing and a TGA check. The agent shows such a suggestion only if the service has validated it. The agent still does not set urgency.

Where the evidence is kept. Every agent step is a trace, stored outside the agent and keyed to the task. Every write to the PAS shows in the PAS audit log, under the agent's own account. Every message stays in the secure messaging log. The original documents stay unchanged in the document store.

What changes in the systems.

  • A referral staging worklist built on FHIR Task, in front of the PAS.
  • New statuses: received, matched, awaiting information, ready for triage, triaged, offered, booked, closed.
  • Event subscriptions for a new inbound document, a reply received and a slot released.
  • An agent service account in the PAS. It can write only referral status, waiting list entries and bookings.
  • HI Service calls use the organisation's existing NASH certificate and are logged per call. Check the HI Service rules if a vendor hosts the agent.

What does not change. The PAS stays the record of the waiting list. State waiting time rules and reporting definitions stay. The specialist team still triages. GP software and the secure messaging networks stay as they are.

Who does this today

No Australian or New Zealand public hospital was found running an agent that takes in, chases and books referrals.

Where this sits

The four questions place this agent.

  • Role. It coordinates. The domain is health referrals.
  • Permissions. These are what its own credentials let it do. It reads referrals, identity details, results and clinic slots. It writes referral tasks, waiting list entries and bookings. It sends secure messages and SMS from templates. It cannot set urgency, decline a referral, or create or merge a patient.
  • Autonomy. It is designed and permitted for delegated tasks (A2) on the autonomy contract. A clerk reviews its output, and fixed rules release routine steps. Urgency and eligibility drop to assisted (A1), where the clinician decides.
  • Impact. It touches none of the four deterministic zones. The rule for decisions about people applies. Urgency, decline and booking out of order shape a decision about a person's health. A named person makes each one. A wrong patient match cannot be undone once the data is seen.

It is Tier 3 (strict), because it reaches regulated health data. It reads untrusted input from outside faxes and messages. It reaches health data, and it sends messages out. That is all three parts of the Rule of Two. So it stays at A2, and it sends only approved templates. Letting templates go without review is a change, so the risk profile is scored again.

Its learning level is fixed (L0). It does not learn from cases. People change its rules and templates at the change stage of the agent lifecycle.

Two of the seven capabilities carry most of the control. Identity and policy gives the agent its own identity (ID2) on the delegation chain. Policy is enforced outside the model: the PAS account refuses any write beyond status, waiting list and bookings. Observability and audit trail keeps every step where the agent cannot touch it.

Measure the result

Compare with the current hub on past referrals first, then in a live trial. Measure these:

  • Time from receipt to ready for triage.
  • Requests sent per referral, and replies that answered them.
  • Wrong patient matches and duplicate bookings. The target is none.
  • Clerk overrides.
  • Cost per referral that reaches a booking or a clear decline. The value and investment page sets out that cost.

Report patient and GP complaints separately. Do not read clinical benefit into booking speed.

Start with a trial

Pick one clinic and one channel, such as the e-referral form. Run the agent on past referrals and compare with what the clerks did. Then run it live with a clerk approving every step. Register the agent with a named sponsor and owner before go-live. Move a step to a fixed rule only when its error rate is known.

Evidence and limits

The steps come from known practice in Australian and New Zealand referral hubs. Step times are typical, unsourced. Volumes exist only as a state total and for single services.

Triage suggestion models are at validation stage. The ReferralAI agreement figure comes from a 2023 study. Vendor results are as the vendor reported them.

Two checks come before a build. Confirm the TGA position before showing any model-suggested category. Confirm the HI Service rules before a vendor hosts an agent that looks up identifiers.

Next step

Follow the patient after discharge on care follow-up. Or go back to the hospital estate.

Explore this topic

Research for this page was done on 15 October 2026.

Standards. HL7 FHIR separates the request, the work and the booking. The R4 ServiceRequest resource holds the request. The R4 Task resource tracks the work. The R4 Appointment resource holds the booking. IHE 360X closed-loop referral closes the loop back to the referrer. These are integration references, not evidence that an agent is safe. Confirm the version and local profiles your systems support.

Sources.

Cite this page

Written by Murali Sid, Founder and AI Systems Architect, last updated 15 October 2026. Licensed CC BY-SA 4.0, so quote it freely with attribution.

Murali Sid (2026). From referral to a confirmed appointment. Agentic Architecture Skills. https://www.agenticarchitectureskills.com/use-cases/referral-coordination

Machine-readable version of this page: /use-cases/referral-coordination.md

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