ToC+-+Scenario+1

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**Please view the Final Use Case page for the most recent version of this section.**


 * //PLEASE NOTE//: In the updated Use Case outline, Scenario 1 will depict Provider to Provider and Scenario 2 will depict Provider to Patient. Also, the Scenario 1 Section is now 10.0 instead of 11.0 because of the deletion of the separate User Story section.**

Introduction to Scenarios
As described in the Scope section, the Use Case has two scenarios: the first focuses on the perspective of provider to provider exchange of clinical summaries The second focuses on the perspective of the providers sending these clinical summaries to patients and their PHR Both scenarios share the same User Stories However, the User Story in the first scenario is presented from the provider to provider perspective and the second scenario is presented from the provider to patient perspective Thus both scenarios are based on the same User Stories and activities, just presented from the two perspectives The actual instance of any of the User Stories and activities must include both perspectives


 * Assumptions**
 * 1) The receiving facility has provisionally accepted the patient for transfer or referral with patient consent and wants the clinical summary.
 * 2) Negotiations between providers are out of band but necessary to assure acceptance of transfer or referral.
 * 3) Agreement to receive by other provider and by patient is necessary for actual transfer or referral of patient. Similarly, agreement to receive the clinical information by the other provider and by the patient is necessary for information exchange to take place.
 * 4) Scenario 1 does not describe transport or end user site activity.
 * 5) The Information exchange can be achieved with or without intermediaries. Using intermediaries should not create any new functional requirements for the exchange of information
 * 6) Same assumptions apply to Scenario 1 and 2.

10.1 User Stories of Scenario 1
The user stories illustrate a combination of events in the scenario flows which are described in further detail in the tables that follow.


 * User Story 1: The Exchange of Information to Support the Transfer of Patient Information from a One Provider to Another**


 * Actors**
 * **Actor** || **Details** ||
 * Provider: Hospital or ED Clinical System || Source ||
 * Provider: Patient's PCP or Care Team || Destination ||
 * Setting 1: Hospital or ED from where patient is discharged (sends discharge summary to PCP or Care Team).**

A patient is discharged from the hospital or ED Discharge instructions are given to the patient by his nurse or care manager on day of discharge at or a short time before the physical discharge. The instructions may be generic, patient specific, or disease specific depending on the facility’s practices and the patient’s needs. The patient acknowledges that he has received the instructions from the nurse (verbally, in writing, and/or electronically). The acknowledgement triggers the physical discharge sequence of events and patient transport out of the facility. The discharge instructions are sent to the patient's Primary Care Physician (PCP) or Care Team (as the instructions may contain information necessary for the PCP or Care Team to follow up with the patient before the discharge summary is available). Upon discharge, the discharge summary is prepared within the Hospital EHR system. The attending physician of record (APoR) reviews the discharge summary and, once he has approved it, the discharge summary is sent to the PCP. The summary may arrive in the PCP’s EHR system even before the patient has left the hospital. A copy of the message may be retained in the hospital EHR per the hospital’s policies and workflow rules.

NOTE: The discharge instructions described above are also part of the discharge summary. If the discharge summary is ready at the time of physical discharge, it is the only document necessary to be sent to the PCP or patient's care team.

Audit logs of the exchange are retained according to the hospitals, PCP’s, and any intermediaries’ policies, procedures, and agreements.


 * Setting 2: Patient's PCP or Care Team (receives discharge summary from Hospital or ED clinical system).**

Discharge summary/instructions are received into the PCP practice’s EHR system. Patient generally will be known in the EHR system in which case an automated EHR match may occur (for example, if the hospital and PCP systems can share a common patient identifier). Discharge summaries/instructions that are not automatically matched to a patient are reconciled manually, which may include the process of creating a new patient record and registering the patient. Once the discharge summary/instructions have become part of the PCP’s EHR system, additional practice variable activities may occur: new tasks may be directed to a front desk staff EHR work queue, as well as to additional staff EHR work queues as appropriate to the practice workflows. Follow-up/plan of care is managed according to established PCP workflow. For example, upon receiving notification of the patient’s status, the care manager is now aware that the patient becomes confused when medications are altered and calls the patient to ensure the patient is taking the correct medications post discharge and is following the discharge instructions

The PCP may review and promote into the EHR the newly reconciled active medications, updated problem lists, new procedures and other discrete data elements. The hospital (or ED) discharge summary/instructions are retained in its entirety as a permanent part of the patient’s record.

//*User story 1 could also be applied to a specialist sending reports back to PCP for follow-up post op or post discharge//


 * User Story 2: Closed Loop Referral**


 * Actors**
 * **Actor** || **Details** ||
 * Provider; PCP's EHR System || Referral Source ||
 * Provider; Specialist's EHR System || Referral Destination ||
 * Setting 1: PCP's office (sends consultation request clinical summary to specialist).**

A PCP is in the middle of an encounter (office visit) with a patient and determines that the patient needs to be referred to a specialist The PCP is documenting the encounter in the EHR and within the EHR prepares the consultation request clinical summary to the specialist. The message is addressed to the appropriate specialist, specialty or provider organization and is sent to the specialist’s EHR system.


 * Setting 2: Specialist's office (receives referral request clinical summary from PCP; send consultation summary to PCP).**

The consultation request clinical summary is processed according to the specific context of the referral. In accordance with practice policies and workflow the specialist reviews the document and orders any additional tests to be performed for the patient prior to the office visit. Discrete data elements from within the summary may be promoted to the specialist’s EHR system.

When the patient arrives at the specialist’s office he is registered in accordance with practice policies and workflow. The specialist documents the encounter in the EHR system and prepares the consultation summary for the PCP. Once the consultation summary is prepared, it is addressed and sent to the PCP’s EHR system. A copy of the message is retained in the specialist’s EHR system.

//*User story 2 could also be applied to a specialist sending reports back to PCP for follow-up post op or post discharge//


 * Return to PCP Setting 1: PCP’s Office**

The consultation summary is received into the PCP practices’ EHR system. Once the consultation summary is received into the EHR system, additional practice variable activities may occur: tasks can be directed to a front desk staff EHR system work queue for appropriate distribution to additional staff’s EHR system work queues, as appropriate to the practice workflows. For example, the front desk staff may schedule a follow-up visit with the patient and alert the PCP of the availability of the consultation summary. If the patient has an assigned Care Manager who follows the patient at an advanced practice care facility (such as a Patient-Centered Medical Home), review alerts may be sent to both the PCP and the Care Manager for appropriate compliance planning. Discrete data elements from within the consultation summary may be promoted to the PCP’s EHR system. In accordance with practice policies and EHR functionality, the PCP may review and promote to the EHR the specialist-reconciled active medication and problem lists, any new procedures may be accepted into the EHR, and any other new discrete data elements may become part the of the patient’s EHR. The consultation summary may be retained in its entirety as a permanent part of the patient’s EHR record.


 * User Story 3: Complex Series of Care Transactions**


 * Setting:** ED


 * Activity:** A Patient is transported to the ED from home in a semi-comatose condition. Her significant other has printed data from the patient’s PHR and has given that to the EMS to give to the ED doctor The patient is admitted to the ED. The ED EHR system receives the patient summary from the patient’s PCP’s EHR system. The ED physician determines that the patient needs to be admitted to the hospital. The patient is admitted to the hospital’s critical care unit. The hospital’s EHR is updated with the ED patient information. The ED EHR system delivers a patient summary of the ED encounter to the patient’s PCP EHR system.


 * Summary Contents: Both basic standard dataset and patient summary message context relevant dataset**

Message should always include //standard// basic dataset:
 * Demographic information, active medication list (with doses and sig), allergy list, problem list, etc.

Summary contains //variable dataset relevant to the context//:
 * Examples: Recent results, vitals, etc.


 * Setting:** Hospital


 * Activity:** A Patient is cared for in a critical care unit. All treating clinicians have access to the information in the Hospital EHR system. The patient’s significant other, who is the patient’s Durable Power of Attorney for Healthcare (DPOA-HC), is staying with the patient in the hospital. The patient’s DPOA-HC requests that copies of changes to patient’s orders be sent directly from the hospital EHR to the patient’s PHR so that he/she can monitor the patient’s care. After several days in the intensive care unit it is determined that the patient would benefit from intensive rehabilitation that is not available at the hospital. The attending physician arranges a discharge from the hospital and transfer for the patient to a Rehabilitation Facility. In accordance with the hospital’s policies and workflow a discharge summary & instructions are prepared by the hospital EHR. The discharge summary and instructions, including recommendations for continuation of open orders, are sent to the Rehab facility EHR. The hospital EHR sends patient’s PCP’s EHR a copy of discharge summary/instructions.

Upon discharge from hospital, the patient is transferred to a rehabilitation facility -- see User Story 1


 * Summary Contents: Both basic standard dataset and Discharge context relevant dataset**

Summary should always include //standard// basic dataset:
 * Demographic information, active //reconciled// medication list (with doses and sig), allergy list, problem list, reason for admission, follow up/discharge instructions etc.

Summary contains //variable dataset relevant to the hospitalization (selected by the clinician who prepared the discharge message)//:
 * Examples:
 * Procedures during hospitalization
 * Relevant results, reports
 * Wound care (if applicable)
 * Speech, Occupational & Physical Therapy orders and Activities of Daily Living (ADL) evaluations
 * Etc.


 * Setting:** Rehabilitation Facility


 * Activity:** The hospital discharge summary/instructions are received in the Rehab facility's EHR system When the patient arrives she is admitted and the EHR updated. The EHR system provides the patient information for review by the lead nurse, lead therapist and physician that will be caring for the patient Once reviewed and approved by the clinicians in accordance with the facility’s policies, protocols and workflows, the information is available to all of the rehab staff that will be caring for the patient. The patient’s PCP receives a summary of the recommended care plan. The patient’s PHR receives copies of rehab case review notes and ADL evaluations so that the DPOA-HC can actively monitor the patient’s progress and assist in planning patient’s discharge destination post-rehab.

Upon completion of the rehabilitation, the patient is discharged to home/PCP -- see User Story 1.


 * Summary Contents: Both basic standard dataset and Discharge context relevant dataset**

Summary should always include //standard// basic dataset:
 * Demographic information, active //reconciled// medication list (with doses and sig), allergy list, problem list, reason for admission,

The Summary contains //variable dataset relevant to the rehab care plan.//
 * Examples include:
 * Therapy orders
 * ADL scores

10.1.1 Base Flow of Scenario 1

 * User Story 1: The Exchange of Discharge Summary to Support the Transfer of Patient Information from One Provider to another Provider.**

(includes Discharge Instructions) || Discharge Summary || END ||
 * **Step #** || **Actor** || **Event/Description** || **Inputs** || **Outputs** ||
 * 1 || Provider || Trigger Generation of Discharge Summary for Patient A || START || Discharge Instructions ||
 * 2 || Hospital EHR System || Send Discharge summary to PCP's EHR System or other Provider EHR System || Discharge Instructions || Discharge Instructions ||
 * 3 || PCP EHR System or other Provider EHR System || Receive Discharge Summary || Discharge Instructions || Discharge Instructions ||
 * ||  || **//Note: If the discharge summary is completed by the time the patient is physically discharged, then only the discharge summary (which includes the discharge instructions) needs to be sent to the PCP EHR system, thus making steps 2 and 3 unnecessary.//** ||   ||   ||
 * 4 || Provider || Trigger Generation of Discharge Summary for Patient A
 * 5 || Hospital EHR System || Send Discharge summary to PCP's EHR System or other Provider /Organization || Discharge Summary || Discharge Summary ||
 * 6 || PCP EHR System or other Provider EHR System || Receive Discharge Summary || Discharge Summary || Discharge Summary ||
 * 7 || Provider || View Discharge Summary/Instructions || Discharge Summary || END ||


 * User Story 2: The Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient from a One Provider to Another**


 * **Step #** || **Actor** || **Event/Description** || **Inputs** || **Outputs** ||
 * 1 || Provider || Trigger Generation of Consult Request Clinical Summary for Patient A || START || Generated Consult Request Clinical Summary ||
 * 2 || PCP EHR System || Send Consult Request Clinical Summary to specialist's EHR System || Consult Request Clinical Summary || Consult Request Clinical Summary ||
 * 3 || Specialist EHR System || Receive Consult Request Clinical Summary from PCP's EHR System || Consult Request Clinical Summary || Consult Request Clinical Summary ||
 * 4 || Provider || View Consult Request Clinical Summary in specialist's EHR System || Consult Request Clinical Summary || END ||
 * 5 || Provider || Trigger Generation of Consultation Summary for patient A || START || Generated Consultation Summary ||
 * 6 || Specialist EHR System || Send Consultation Summary to PCP's EHR System || Consultation Summary || Consultation Summary ||
 * 7 || PCP EHR System || Receive Consultation Summary from specialist's EHR System || Consultation Summary || Consultation Summary ||
 * 8 || Provider || View Consultation Summary in PCP's EHR System || Consultation Summary || END ||


 * User Story 3: Complex Series of Care Transitions (*//Note: Events of this User Story are reflected in the Simple ToC User Story//*)**

10.1.2 Activity Diagram for Scenario 1
The following are the Activity Diagrams to support the events in section 10.1.1.


 * User Story 1: The Exchange of Discharge Summary to Support the Transfer of Patient Information from One Provider to Another Provider.**


 * User Story 2: The Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient from a One Provider to Another**

10.2 Functional Requirements of Scenario 1
10.2.1 Information Interchange Requirements of Scenario 1
 * **Initiating System** ||  || **Information Interchange Requirement Name** ||   || **Receiving/Responding System** ||
 * Hospital/ED EHR System || Send (A.XFER.1)* || Discharge Summary || Receives (A.XFER.2) || PCP EHR System ||
 * PCP EHR System || Send (A.XFER.1) || Consultation Request Clinical Summary || Receives (A.XFER.2) || Specialist EHR System ||
 * Specialist EHR System || Send (A.XFER.1) || Consultation Summary || Receives (A.XFER.2) || PCP EHR Systgem ||
 * This identifier comes from the ONC SI-UC-Simplification spreadsheet (see References)

10.2.2 System Requirements of Scenario 1

 * **System Requirement Name** || **System** ||
 * Display Discharge Summary || PCP EHR System ||
 * Display Consultation Request Clinical Summary || Specialist EHR System ||
 * Display Consultation Summary || PCP EHR System ||

10.3 Sequence Diagrams of Scenario 1
The following sequence diagrams describe the messages and order of messages.


 * User Story 1: The Exchange of Discharge Summary to Support the Transfer of Patient Information from One Provider to Another Provider.**

**//PLEASE NOTE: The downloading of Patient Information to the PHR is included in Scenario 2: Exchange of Clinical Summaries between Provider to Patient.//**


 * User Story 2: The Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient from a One Provider to Another**

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