ToC+-+Final+Use+Case+Consensus

include component="page" wikiName="siframework" page="TOC Header" = = = = Prior comment: I will be willing to change my vote to Yes provided we address two concerns: 1) As commented by Susan Campbell and others she cites, and 2) It is my best estimation that our rush to complete led many of us to bring in excellent "technical artifacts" that have yet to be field-tested and confirmed to enable "reasonable deployment." As I understand the charter I accepted as a Committed Member, this point should not be swept aside, but rather raised, understood and resolved.
 * **Name** || **Organization** || **Endorsement**
 * (Yes or No)** || **If No, what can be changed to make it Yes?** ||
 * Steven Waldren || AAFP ||  ||   ||
 * J. Michael Fitzmaurice || AHRQ || No || I agree with Susan Campbell that PHR access to data in Scenario 1 should be addressed. The opportunity for the patient to download his/her information (say, discharge summary) to his/her PHR should be provided upon patient request. I agree generally with the scenario descriptions and addressing this point would change my vote to Yes. ||
 * David C. Kibbe || American Academy of Family Physicians ||  ||   ||
 * Anne Diamond || American College of Obstetricians and Gynecologists (ACOG) ||  ||   ||
 * James Scroggs || American College of Obstetricians and Gynecologists (ACOG) || Yes, with question - || When patients are discharged from the hospital, they are usually seen by the treating physician in that physician's office one or more times before care is transferred back to the patient's primary care physician. Does the use case account for the treating physician's post-hospital-discharge care and any final instructions when care is discontinued? Should it? ||
 * Thomson Kuhn || American College of Physicians (ACP) || Yes ||  ||
 * Greg Alexander || ANI ||  ||   ||
 * Seonho Kim || ApeniMED (formerly MEDNET) ||  ||   ||
 * Amber Broadwater || Avisena Inc. || Yes ||  ||
 * Lin Wan || Axolotl Corp. ||  ||   ||
 * Paula Gwyn || CareTech Solutions ||  ||   ||
 * Gary Dickinson || CentriHealth || Yes ||  ||
 * John Odden || Coto Partners, AIIM, CGC, C4UH || Yes, but || WIth the 3 statements Arien mentioned, resolving #2 and #1 also resolved on the team call 4/6/2011.

Yes, there may be another means to address this point and I'm fully open to that possibility. ||
 * Chris Doucette || Deloitte ||  ||   ||
 * Randolph Sanks, MBA || Deloitte (Health and Life Sciences) ||  ||   ||
 * Susan E. Campbell, PhD, RN || Deloitte Consulting, LLC Federal Strategy & Operations || Yes || The concensus discussion addressed all the points below to satisfaction, relying especially on Arien Malec's expression of ONC intent to address access to patient via his/her PHR in later stages of the S&I Framework process, which he indicated would be prioritized after Stage 1 and Stage 2 Meaningful Use aspects which must be addressed first. This note supercedes my summary of concerns below and encompasses their intent:

I will be willing to change my Yes, but vote to Yes if the following issues are addressed in keeping with similar requests made by Fitzmaurice, and echoed in remarks of Nedza, and Dickerson, and Mota, and with addition of Garber's recommended edits on patient safety. I would need to keep that changed "yes" to be "yes, but" until Keepper's concern with audit trail is resolved, though I don't understand the comment of "at first glance." If he means audit trail visible to all who have access, including the patient, I agree with that caveat:

(1a) User Stories Scenario 1. Discharge summary to PCP or Care team does not mention sending information to PHR. This is addressed appropriately in Scenario 2. Both should match or be linked rather than leaving the impression to anyone they might be mutually exclusive. "Nothing about me without me" was the way one of the others summed up. I don't think we discussed MD to MD discharge information in the absence of sending information to patient. If User Story Scenario 1 is a step building to Scenario 2, Setting 1 and this is the reason for no info to PHR, User Scenario 1 is superfluous and should be eliminated. If I could toggle between them I might be able to see how this is solved, but I can't toggle or see them side-by-side to be sure. Alternatively, you could add the option to provide download to PHR at patient request if PHR can accept the information. People in our group were emphatic that all the information available to PCP and Care Team should be available to the patient at patient option. We had a specific discussion about the value of patient receiving automated notification when a referral for consult has occurred. (At that time we addressed the audit trail issue raised by Keeper. There was at least one other time we discussed audit trail, when I spoke of points at which data could be extracted for meaningful use measures. I don't know how to resolve this technically though I think it should be resolved - will this happen at the standards and harmonization stage? Can we provide a recommendation as an outcome of this process to standards and harmonization that would resolve Keeper's concerns?)

As a fundamental tenet, there should be no lack of clarity on the aspect of patient "opt-in" recommended by Nedza. A final option is to add a note referring at the end of Scenario one to to Scenario 2 for information about downloading information to patient PHR, to indicate this is intended to occur whenever documents, data, or other information are transferred from one E.H.R. to another. Apologies if my "no" stems from my newness to this process. That will be quickly remedied with a clear explanation in writing about how these concerns are being addressed. Thanks.

The remaining edits are all details (easy to fix): (2) Recommend not using term "Minimal Dataset" (or "Minimum Dataset") because someone will start using acronym MDS that means something specifically different in long term care. Suggest using "Basic Dataset" - acronym BDS has no other meaning to my knowledge (or use some other synonym to "basic"). (3) Define acronym DPOA used to refer to Setting:Rehab. (4) Scenario 2, Setting 1 - first sentence is nonsensical, needs rewriting. (5) Change last (red) line to read "Patient receives a summary to PHR." (6) Be consistent in using "consult" or "consultation" - suggest the shorter one to save space (7) 11.1.2 Activity Diagram for Scenario 2: in blue box, change "HER" to read "E.H.R." 12.0 The word "not" is missing which reverses meaning of the sentence. Revise it to read: Policies do not exist..." as you are describing the current state of affairs not the future state. (8) in Dataset for Discharge Instructions in line reading "follow up/plan of care..." you need either one more or one less parenthesis. (9) Suggest you replace "forward looking" with the term we used "prospective," otherwise you are bound to use "backward looking" elsewhere when you want to say "retrospective." (10) in ADDED section, define (O/N). There are too many slashes, use commas. (11) in Dataset for Discharge Summary: "Discharge" in mid-sentence should read "discharge" and add the word "to" in "determine how to incorporate." (12) Define the acronym SWG. (13) column 2, substitute "previously" for "prior" (14) in TCC.20 change "need" to "needs" in column 3 (15)T.CC.32 the word "Date" should be lower case. (16) T.CC.33 same as (15). (17) T.CC.37 "Description" should be lower case. (18) "Providers" should read "Provider" as definition is singular. (19) Provider Organization is defined, but in Use Case we used "Provider" to mean both. I recommend we write everywhere we mean both as follows: Provider/Provider Organization (P.O.) and then contract to: Provider/P.O. or something like that.

Aree with Garber's recommendations re: patient safety. ||
 * Tom Dawson || Dispersive Medical ||  ||   ||
 * Stephen Hufnagel || DoD Military Health System ||  ||   ||
 * Jim Hansen || Dossia Consortium || No, until ... || Dr. Nedza comment about the proposed ACO regs (and I would add Medical Homes) and are right on target - The concept of "nothing about me, without me" should be the guiding principal for all of our work - we collectively forget that without patients there is no health care industry. Bonuses from ACO and MH outcome based payments structures cannot be maximized without patient engagement and self-management - neither of which can happen if they do not have the data to be a active member of the care team Any time health information is sent to anyone, the patient should have the option (as designated in the preferences section within the EHR) to have a copy sent to them through secure messaging (a component that the Meaningful Use work group broadly supported in their 4/5 meeting) to the patient and/or their proxy (e.g. PHR, HIE, VA, etc.). Secure messaging currently defined as "Direct" and "Connect".

Dr. Garber's suggested changes are incorporated in their entirety (thank you for your incredible attention to detail!).

Susan Campbell's initial posting of proposed changes - Based on the comment I made above, it is not appropriate to postpone consumer/patient elements until a later phase of the project. || (1) The user stories for scenario 1 and scenario 2 are supposed to be identical. Currently they are not, giving the impression that the user stories are independent, while the actual intent was to express provider/provider exchange in scenario 1 and provider/patient interaction in scenario 2 for the same user stories. (2) The Data Set Considerations need to be marked as informative, and a request made to the Harmonization Workgroup to specify the guidelines for: (a) Patient level summary data set (information independent from a particular encounter) (b) Base Data Set for Discharge Summary (c) Base Data Set for Referral Request Summary the current tables are confusing and mix various kinds of information (3) Enhance the assumptions under 10.0 (a) extend number 3 as follows: Agreement to receive by other provider and by patient is necessary for actual transfer or referral of patient. **Agreement to receive clinical information by other provider or by patient is necessary for the information exchange to take place.** (b) add the following (as an assumption, or a note) (4) Under 2.0, number 1 and 2 of the successful outcomes are actually metrics, and not outcomes. In addition to the major issues above, there are dozens of smaller issues, typos, etc. which will need to be corrected as well. A marked-up copy of the suggested edits will be provided, based on the resolution of the above. || • T.CC.16 Hospital Discharge Medications - Add to the Additional Notes second bullet "including time of last dose and whether patient was sent with samples of the medication(s)**."** • T.CC.18 Advance Directives - Add a second bullet under Additional Notes "Whether a Healthcare Proxy has been invoked." • T.CC.31 Medical Equipment - includes assistive devices and is related to functional status - Add a bullet under Additional Notes "Includes reading glasses, hearing aids, dental appliances, etc…" • Add another section "Patient Risks" with a content "Falls, Elopement, etc…" and notes "Strategies to mitigate patient risks" • Add another section "Risks to Others" with a content "Contagion, violent behavior, etc…" and notes "Isolation requirements, etc..." In the **Dataset for Discharge Summary:** • T.CC.16 Hospital Discharge Medications - Add to the Additional Notes "including whether patient was sent with samples of the medication(s)**."** • **T.CC.*17 Medications Administered - Add to the Additional Notes "including time of last dose**."* • T.CC.18 Advance Directives - Add a second bullet under Additional Notes "Whether a Healthcare Proxy has been invoked." • T.CC.31 Medical Equipment - Add a bullet under Additional Notes "Includes reading glasses, hearing aids, dental appliances, etc…" • Add another section "Patient Risks" with a content "Falls, Elopement, etc…" and notes "Strategies to mitigate patient risks" • Add another section "Risks to Others" with a content "Contagion, violent behavior, etc…" and notes "Isolation requirements, etc..." ||
 * Kyle Meadors || Drummond Group Inc. ||  ||   ||
 * Vassil Peytchev || Epic || No || The following general issues need to be resolved:
 * The scope of the Use Case precludes certain workflows from consideration (for example sending only a notification of discharge to the PCP, and allowing the PCP to decide if and when to query for the actual discharge summary). This should not be construed to mean that a requirement for workflow modification is necessary for the exchange of clinical information - the scenarios presented here represent only one way of achieving that objective.**
 * Larry Garber, MD || Fallon Clinic/SAFEHealth || Yes, but || In the **Dataset for Discharge Instructions:**
 * John Williams || Garden State Health Systems Inc / Health-ISP.com ||  ||   ||
 * Ruth Berge || GE Healthcare IT ||  ||   ||
 * Steve Rushing || Georgia Institute of Technology || Yes ||  ||
 * Greg Smith || Greg Smith and Associates || Yes ||  ||
 * Jaime Estrada || Health Information Network of Arizona || Yes ||  ||
 * Simpson William || Healthland ||  ||   ||
 * Susan Nedza MD || HealthyCircles, LLC. || Yes, but || Agree with Susan Campbell. Scenario 1 must include PHR. I believe that it should be an "opt-in" option for the patient. The NPRM for ACO's that was released by CMS on April 1st, supports the need for "Patient-Centeredness" and much of what an ACO will need to do will require full patient engagement. ||
 * Louise V. Fryer, RN, MS, PMP || Highmark Blue Cross Blue Shield ||  ||   ||
 * Audrey Dickerson || HIMSS || Yes || Agress with Susan Campbell on scenario1. The patient and his/her PHR must be included. ||
 * Joyce Sensmeier || HIMSS ||  ||   ||
 * David Cheng || IBM ||  ||   ||
 * Aaron Stranahan || ICA ||  ||   ||
 * Adora Bruce || ICA ||  ||   ||
 * Mayuri Patel || ICA || Yes ||  ||
 * Tim Dunnington || ICA ||  ||   ||
 * John Moehrke || IHE ITI ||  ||   ||
 * Keith Boone || IHE PCC Domain ||  ||   ||
 * Michael J. McCoy, MD || IHE PCC, ACOG, Catholic Health East ||  ||   ||
 * Scott Serich || IJIS Institute ||  ||   ||
 * John Donnelly || IntePro Solutions, IHE || Yes, but || Agree with comments made regarding transparency of discharge summary with patient however this is likely to change the scope and the characteristics of the patient-provider interaction considerably as part of this discharge activity. Currently, the dialogue revolves around the discharge instructions vs a detailed explanation of one or more of the clinical elements of the medical summary document. This is not a bad thing as the objective is more transparency and more consumer engagement in the health care process...just potentially something new to the workflow that needs to be worked through for implementation. We certainly don't want to hold up the deployment of the provider -to- provider ToC being implemented by a "surprise" pre-requisite for the provider for his/her required interactions with the patient.

This should definitely be a patient "opt-in" as was expressed by Dr Nedza. This will help the provider be aware of and be prepared for this new level of patient-provider dialogue if not already part of the discharge process. ||
 * Cyndalynn Tilley || Intermountain Healthcare || Yes || and I agree with Dr. Garber's suggestions for additions to discharge instructions. ||
 * Larry Wolf || Kindred Healthcare ||  ||   ||
 * Jeff Bloemker || Lewis And Clark Information Exchange ||  ||   ||
 * Corey Spears || McKesson ||  ||   ||
 * Holly Miller, MD, MBA || MedAllies || Yes ||  ||
 * Vasu Iyengar || MedAZ.net, LLC ||  ||   ||
 * Adrian Gropper || MedCommons ||  ||   ||
 * Mark Bamberg || MEDfx ||  ||   ||
 * Eric Heflin || Medicity ||  ||   ||
 * Luann Whittenburg || Medicomp System, Inc. ||  ||   ||
 * Fred Buhr || Metasteward LLC || Yes ||  ||
 * Paul Edge || Microsoft ||  ||   ||
 * Larry Sampson || Minnesota Health Information Exchange (MNHIE) ||  ||   ||
 * Konda Mullapudi || Misys Open Source Solutions (MOSS) LLC. ||  ||   ||
 * Lynne Gilbertson || NCPDP ||  ||   ||
 * Teresa Strickland || NCPDP ||  ||   ||
 * Thomas Foley || NextEnt, LLC ||  ||   ||
 * Steven Saitsky || NextGen Healthcare ||  ||   ||
 * Russell B. Leftwich, MD || Office of eHealth Initiatives, State of Tennessee || Yes || Editorial comments: Table for Scenario 1 in 10.1.1 on lines 1,2,3 shows event as generate discharge summary but inputs and outputs are discharge instructions. Sections 10.2.1 and 10.2.2 refer to PCP sending a referral request. I believe that a PCP makes a referral but sends a consultation request. ||
 * Kimberly Tooles || Onyx Home Health Care, LLC. ||  ||   ||
 * Lola McCune || Onyx Home Health Care, LLC. ||  ||   ||
 * Brian Ahier || Oregon HIE Planning Team || Yes ||  ||
 * Elizabeth Evans || PANDA and Associates, LLC ||  ||   ||
 * Perry D. Cohen, PhD || Parkinson Pipeline Project ||  ||   ||
 * Elaine A. Blechman || Prosocial Applications, Inc. ||  ||   ||
 * Teresa Mota || Quality Partners of Rhode Island || Yes, but || Only with the additions mentioned by Dr. Garber and Susan Campbell. ||
 * Freida Hall || Quest Diagnostics, Inc. ||  ||   ||
 * Ken McCaslin || Quest Diagnostics, Inc. ||  ||   ||
 * Bob DeAnna || Recursion Software || Yes ||  ||
 * Will Ross || Redwood MedNet ||  ||   ||
 * Ernest Grove || SHAPE HITECH LLC || See reponse from Lester Keepper ||  ||
 * Lester Keepper Jr. || SHAPE HITECH LLC || No || The ToC Use Case states, "The Standards and Interoperability (S&I) Framework is an investment by the country in a set of harmonized interoperability specifications to support national health outcomes and healthcare priorities. **//__In order for S&I to achieve specific health interoperability initiatives "__//**

The value of this whole system must be accepted by the user. Without a complete, __recognizable__ __audit trail at first glance__, there is no assigned or traceable responsibility for each step of the process, and therefore no value to the user. ||
 * Doug Pratt || Siemens || Yes ||  ||
 * Lorre Pacheco || Sunquest Information Systems ||  ||   ||
 * Betty Levine || Telemedicine Advance Technology Research Center/Department of the Army ||  ||   ||
 * Ollie B. Gray || Telemedicine Advance Technology Research Center/Department of the Army || Yes ||  ||
 * Virginia Lorenzi || The NewYorkPresbyterian Hospital ||  ||   ||
 * Tory Berger || TJB Consulting || yes, but || with the 3 statements Arien mentioned ||
 * Philip DePalo || Towson University ||  ||   ||
 * Yeong-Tae Song || Towson University ||  ||   ||
 * Catherine Hoang || VA ||  ||   ||
 * Holly Miller || VA ||  ||   ||
 * Patricia Greim || VA ||  ||   ||
 * You-Ying Whipple || VA ||  ||   ||
 * Terry Hearn || WellPoint ||  ||   ||

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