California+ToC+Brief

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** PROJECT BRIEF: [California ToC Pilot] ** ** Sponsor(s)/Contact(s): Organization Name and Contact Name **
 * **Organization Name** || **Contact Name** ||
 * Cal eConnect || Aaron Seib ||
 * San Diego Beacon Community (SDBC) || Anupam Goel ||
 * Redwood MedNet (RWMN) || Will Ross ||

** Objectives ** Use Case that will be demonstrated: > > > Service that will be demonstrated: This document provides a high-level description for the California Transitions of Care (ToC) Pilot between two Health Information Handling Organizations, specifically the San Diego Beacon Community (SDBC) and Redwood MedNet (RWMN). Provider organizations from both the SDBC and RWMN will participate as both a source and destination related to this piloting of the use of ToC content standards in “inter-HIE” exchange. Additional HIHs from California will be encouraged to participate and added to the pilot in the future. Two use cases will be covered in this pilot project. =Exchange of information from provider to patient= ** Participants/Stakeholders **
 * The Exchange of Clinical Summaries from Provider to Provider.
 * The Exchange of Clinical Summaries to a Patient in support of the Transfer of a Patient from a Care Setting.
 * 1) The exchange of information from provider to patient
 * 2) The exchange of information from one provider to another provider
 * Description **
 * ==Primary care provider’s electronic health record==
 * 1) Patient instructions sent to the patient’s personal health record at the conclusion of the visit via Direct.
 * 2) Respond to Direct queries from a patient’s personal health record for any test results or documentation that may have been incomplete from a prior query. Include a flag that states if the patient’s chart still has incomplete documentation or lab/radiology tests that require additional requests for data in the future.
 * 3) Upon receiving the patient instructions via Direct message, automatically send a Direct message to the patient’s primary care provider electronic health record in three days to request a finalized copy of the visit note and any test results.
 * 4) Use the flag from the patient’s electronic health record about incomplete information to determine if follow-up Direct messages are needed to access additional information.
 * ==Patient’s personal health record==
 * 1) Upon receiving the patient instructions via Direct message, automatically send a Direct message to the patient’s primary care provider electronic health record in three days to request a finalized copy of the visit note and any test results.
 * 2) Use the flag from the patient’s electronic health record about incomplete information to determine if follow-up Direct messages are needed to access additional information.

1.1 Hospitalist’s electronic health record

 * 1) Discharge instructions sent to the patient’s personal health record via Direct.
 * 2) Respond to Direct queries from a patient’s personal health record for any test results or documentation that may have been incomplete from a prior query. Include a flag that states if the patient’s chart still has incomplete documentation or lab/radiology tests that require additional requests for data in the future.
 * 3) Respond to Direct queries from a primary care provider’s personal health record to provide a copy of the discharge summary and all relevant test results.

1.2 Patient’s personal health record

 * 1) Receiving the discharge instructions prompts the personal health record to message the primary care provider via Direct.
 * 2) Upon receiving the discharge instructions, send a Direct message to the hospitalist’s electronic health record in three days to request a finalized copy of the discharge summary and any test results.
 * 3) Respond to Direct queries from a primary care provider’s personal health record to provide


 * 1) A consolidated care summary (via Direct message)
 * 2) A document library showing all available documents that the patient is willing to share with the requesting organization (via an XDS.b interface)

1.3 Primary care provider’s electronic health record

 * Option 1 – upon receiving the Direct message from the patient’s personal health record, send a Direct message to the hospitalist’s electronic health record for a copy of the discharge summary.
 * Option 2 – upon seeing the patient register for their appointment with the primary care provider, send a Direct message to the patient’s personal health record to view the patient’s health information.


 * ** Organization ** ||  ** Participant/Stakeholder **  ||  ** Roles ** **and** **Responsibilities**   ||
 * Cal eConnect || Coordinator || Support and Coordination ||
 * SDBC || Participant || HIE ||
 * RWMN || Participant || HIE ||

** Anticipated Available Pilot Resources ** ** Pilot Project Time Line ** ** Success Metrics **
 * Personnel
 * Infrastructure
 * S&I Contractor technical assistance/support
 * Other
 * ** Milestone ** ||  ** Target Date **  ||  ** Responsible ** **Resource**   ||
 * Pilot Acceptance ||  ||   ||
 * Pilot Nomination ||  ||   ||
 * Pilot Design & Development ||  ||   ||
 * Virtual Integration ||  ||   ||
 * ONC Feedback ||  ||   ||

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