Transitions+of+Care+Quickstart+Page



= = This Quickstart page contains resources, artifacts, and key deliverables pertaining to the ToC Initiative in each phase of the S&I framework, from background materials to implementation guidance and educational artifacts. = Why should we improve the exchange of core clinical information in care transitions? = = = The Transitions of Care (ToC) Initiative was developed with the intent of improving the exchange of core clinical information among providers, patients, and other authorized entities electronically in support of Meaningful Use and IOM-identified needs for the improvement of patient care. The initiative supports national health initiatives, key healthcare stakeholders and healthcare priorities and is driven by one compelling question:

**//"What if every care transition was enabled by an unambiguously-defined core set of high-quality clinical data?"//**

The ToC Initiative **enhances the quality of patient care** through increased healthcare provider's access to information in the instance of a transition of patient care and, **reduces the cost and time** required to implement the recommended Consolidated CDA standard by providing comprehensive and clear implementation guidance. The immediate value provided from this initiative is a Meaningful Use Stage 1 summary of care (Eligible Provider, Eligible Hospital, and Critical Access Hospital) for a care transition, including a transition of care to consumer. The value delivered is focused on 4 key information exchange constructs, defined in the Transitions of Care Use Case, available below.
 * **//Discharge Summary://** A clinical document used in the event that a patient is discharged from a healthcare provider. This document contains a standard set of information to be communicated from one provider to another provider in accordance with local policy, regulations and law. Document content includes demographic information, active reconciled medication list (with doses and sig), allergy list, problem list, and reason for admission.
 * **//Discharge Instructions://** Contains the standard set of information to be communicated from a provider to a patient (or also to another provider) and includes follow-up or plan of care. The Discharge Instructions may be generic, patient-specific, or disease-specific depending on the facility’s practices and the patient needs. The document includes standard basic data set including demographic data, active reconciled medication list (with doses and sig), allergy list and problem list. The document is given to the patient by their care manager before physical discharge and upon patient acknowledgement, the physical discharge is triggered.
 * **//Consultation Request//:** Consultation Request including Clinical Summary contains information to be communicated by a provider in connection with a consult request to another provider. In addition to the components of the Consultation Request, the Clinical Summary document also includes PCP-selected referral-specific variable dataset. The Clinical Summary is an after-visit summary document that may contain variable data relevant to the context of the request and is sent to the PCP’s EHR as well as the patient’s PHR.
 * **//Consultation Summary//:** Information communicated from a consulting provider to a requesting provider in relation with a consult. The PCP physician prepares the Consultation Summary in accordance with practices and policies. The Consultation Summary always includes standard basic data set including demographic information, active reconciled medication list (with doses and sig), allergy list and problem list. Consultation Summary contains variable dataset relevant to the context of the request.

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S&I Framework Transitions of Care Initiative Background Resources
If you are looking to get started with the Transitions of Care Initiative, start by reading some of the background materials produced. This will give you a good start at understanding the challenges of care transitions, the approach taken by the S&I Framework to address these challenges, and the building blocks necessary as an implementer.

**I want to understand the context of this initiative and what community-led decisions were made** (click below for documents and links): Defines the Transitions of Care Initiative scope and provides a detailed background on the need for the ToC initiative. ||= Final ||~  || **I want to build an architecture that supports a care transition information exchange** (click below for documents and links): **I want to understand the clinical perspective in care transitions** (click below for documents and links): **I want to participate in a care transition pilot or get started writing care transition solutions** (click below for documents and links): Return to top
 * = **Type** || **Name** || **Description** ||= **Version** ||~  ||
 * = [[image:siframework/word_icon.png link="file:siframework/SIFramework_ToC_UC_v 1.1.docx"]] || [[file:siframework/SIFramework_ToC_UC_v 1.1.docx|Transitions of Care Use Case]] || Word document containing the initially defined use case for the ToC Initiative.
 * = [[image:siframework/excel_icon.png link="siframework/ToC - Functional Requirements and Datasets Review"]] || ToC Functional Requirements || Spreadsheet mapping the functional requirements and data sets contained in the Transition of Care Use Case. The document provides a way to visualize interfacing systems, actors & requirements for information interchange scenarios. Use this to track templates, content modules, and elements across the four main information exchange documents, described above. ||= Final ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/ToC Document Types"]] || ToC Document Types || This wiki page provides an overview of the four main information exchange documents involved in an instance of transition of patient care, as defined by the Transitions of Care Use Case. ||= Final ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/TOC Ecosystem Consensus"]] || ToC Consensus Statement || Provides the ToC Consensus for recommending the Consolidated CDA standard. Read this for a background of how and why the C-CDA standard was chosen for the Transitions of Care Initiative. ||= Final ||~  ||
 * = **Type** || **Name** || **Description** ||= **Version** ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/ToC Deployment Models"]] || ToC Deployment Models || Wiki page that contains candidate models that will be developed by the S&I community. Read this for examples of how organizations might deploy the ToC capabilities created by the ToC Initiative. ||= Final ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/ToC RI Architecture"]] || ToC Architecture || Wiki page that contains the ToC architecture methodology, definition, drivers, and assumptions. Refer to this page for guidance to create a robust ToC Reference Implementation architecture. ||= Final ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/TOC Policy and Service Analysis"]] || ToC Policy Requirements || Wiki page that contains the linkages to policies/services for implementation ToC specifications. Refer to this page for the policies and services analysis guidance when implementing specific aspects of a transition of care. ||= Final ||~  ||
 * = **Type** || **Name** || **Description** ||= **Version** ||
 * = [[image:siframework/excel_icon.png link="siframework/Google Spreadsheet of CIM Mappings"]] || Data Element Mapping || Maps priority content to be included in transitions in care to other commonly used clinical information models. Read this for a reference on how the CIM was first developed. Please note that the CIM has been shifted over to the Clinical Element Data Dictionary (CEDD) to ensure greater consistency with regard to the representation of ToC data elements ||= Final ||
 * [[image:siframework/wiki_icon.png]] || Transitions of Care CEDD || The Transitions of Care (ToC) Clinical Element Data Dictionary (CEDD) represents the clinician perspective of clinical data required in care transitions to fulfill the ToC Use Case.The ToC CEDD provided the basis for the development of the S&I CEDD, which is used to capture data elements from each of the S&I Framework Initiatives. ||= Final ||
 * = **Type** || **Name** || **Description** ||= **Version** ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/S&I Framework RI Development Process"]] || S&I OSS Development Process || Defines standards and common practices for collaborative software development. Read this to understand the collaboration process for the reference implementation. ||= Final ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/ToC Development Setup Guide"]] || ToC Development Guide Set Up || Provides a step by step listing of directions in order install the the necessary software, programs and source code to setup a development environment. This page should be read for guidance on setting up a Development environment for ToC. ||= Final ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/ToC Reference Implementation Developer's Guide"]] || ToC Reference Implementation Developer's Guide || Wiki page that lists the development tools used for the ToC reference implementation. Read this for unambiguous implementation and development guidance for the ToC RI project. ||= Draft ||~  ||
 * = [[image:siframework/wiki_icon.png]] || Pilots Website || Wiki page that lists out guidelines and criteria for acceptance of pilots, proposed pilot projects, interested S&I community members as well as a sample Pilot configuration. Use this page to learn more about process of starting a pilot and to access supporting guidance and templates. ||= Live ||~  ||

Transitions of Care Implementation Guidance Resources
This section is your quick, one-stop shop for all things implementation. As a developer coding care transition solutions, or an architect or manager in the field building solutions to solve care transition challenges, you can quickly access guidance, models, and working code to help you build your solution. ||  Companion Guide to C-CDA for MU (web) || Document that provides guidance on how the Consolidated CDA standard is to be applied to the four instances of a transition of patient care. Implementation of the transitions of care ensures compliance with the following Meaningful Use criteria: provides an Electronic Copy of Health Information, Electronic Copy of Discharge Instructions, and Clinical Summary for each Office Visit. Read this if you're interested in transitioning to the Consolidated CDA standard. ||= 3.1 ||~  ||
 * = **Type** || **Name** || **Description** ||= **Version** ||~  ||
 * = [[image:siframework/word_icon.png link="http://www.hl7.org/documentcenter/public/ballots/2011SEP/downloads/CDAR2_IG_IHE_CONSOL_R1_D2_2011SEP.zip"]] || [|Consolidated CDA Implementation Guide] || The Consolidated CDA Implementation Guide provides guidance on how to adopt the CDA standard. Read this if you're an implementer and want background or guidance on how to implement the CDA standard. ||= 2.0 ||~  ||
 * = [[image:siframework/word_icon.png]]
 * = [[image:siframework/excel_icon.png link="siframework/TOC Clinical Information Model"]] || Transitions of Care Initiative CEDD || In addition to addressing the need for an unambiguously-defined core set of clinical data, the ToC CEDD is intended to serve as a logical overlay and neutral representation of the data needed to support care transitions. The value proposition inherent in the ToC CEDD is that it:
 * Provides a view for clinicians into the type of data needed to support each care transition
 * Provides implementers and vendors an idea of how to store and exchange that data
 * Serves as a logical view of the common data model that underlies all care transitions

In practice, it will manifest itself as physical data within an organization engaged in care transitions. The work on the ToC CEDD was guided by practicing clinicians and other implementers who were interested in creating a simple, easy-to-understand model for functional stakeholders to use. ||= 2.0 ||~  || Return to top
 * = [[image:siframework/wiki_icon.png link="siframework/Transitions of Care Direct Profile - Proposed"]] || ToC Direct Profile || The Direct profile lays out an implementation path for those implementers who wish to exchange the Transition of Care clinical documents without being overly constraining in specifying transport, privacy, or security specifics, to allow for customization and optimization in support of specific environments. Read this for protocols for transport and security to exchange care transition information using Direct. ||= 1.0 ||~  ||
 * = [[image:siframework/wiki_icon.png]] || ToC Mod Spec Profile || Similar to the ToC Direct profile, The Mod Spec profile lays out an implementation path for those implementers who wish to exchange the Transition of Care clinical documents without being overly constraining in specifying transport, privacy, or security specifics, to allow for customization and optimization in support of specific environments. However the scope of this profile covers specific transactions and content that are specific to a care transition from one NwHIN participant to another NwHIN participant, or to transactions that may occur from one NwHIN participant to a participant not currently connected to the NwHIN. The specific scope of this profile differs from other S&I Framework profiles in that it supports numerous architecture approaches that might be used by an Exchange partner. Read this to learn more on using NwHIN protocols as a transport method for the four key ToC related information exchanges. ||= 1.0 ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/ToC Reference Implementation & Pilots WG"]] || ToC Reference Implementation || The ToC Reference Implementation (RI) is a model-driven, loosely coupled framework aimed at composing and decomposing Information Packages (IPs) specified as part of the ToC Initiative. The driving models integrated with the RI are products of the Model-Driven Health Tools (MDHT) system representing the IPs and the underlying standard specifications such as CDA, C48, and C83. Read this Workgroup page to access a reference library of ToC data formats, Information Package outputs and overviews of the demonstrations and pilots of the tools developed. ||= Live ||~  ||

Care Transition Communication and Educational Materials
Want to get an idea of what care transitions are and what the standards involved mean? Need resources to help in crafting a potential care transition solution? The S&I Framework has put together a collection of marketing and communication aids for organizations and pilot programs that are interested in learning more about the value of electronic exchange of care transition information. In addition, a series of informative one-page guides are provided to educate the healthcare community on the standards used for care transitions. Return to top
 * = **Type** || **Name** || **Description** ||= **Version** ||~  ||
 * = [[image:siframework/pdf_icon.png link="siframework/Transitions of Care Direct Profile - Proposed"]] || [[file:siframework/TOC One Pager.pdf|Transitions of Care One Pager]] || Read this one page resource for an answer to "what is TOC?" Includes a high level overview of the initiative and a look at the challenges, solutions, and results. ||= Final ||~  ||
 * = [[image:siframework/pdf_icon.png link="file:siframework/Clinical Documentation Architecture (CDA) - One Pager v2.pptx"]] || [[file:siframework/Clinical Documentation Architecture (CDA) - One Pager v2.pptx|CDA One Pager]] || Read this one page resource to understand the purpose, background, and work of the of the Consolidated CDA project within HL7. ||= Final ||~  ||
 * = [[image:siframework/wiki_icon.png link="siframework/Model Driven Health Tools (MDHT)"]] || Model Driven Health Tools || Refer to this series of Wiki pages for an overview of Model Driven Health Tools (MDHT) as well as the technology architecture, key success stories, and key resources associated with MDHT. ||= Final ||~  ||

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media type="custom" key="13277914" Provides the ToC Consensus for recommending the Consolidated CDA standard. The Discharge Summary is the clinical document used in the event that a patient is discharged from a healthcare provider. This document contains a standard set of information to be communicated from one provider to another provider in accordance with local policy, regulations and law. The Discharge Summary content includes demographic information, active reconciled medication list (with doses and sig), allergy list, problem list, and reason for admission. http://wiki.siframework.org/Transitions+of+Care+Initiative+CEDD