ToC+-+Overview+and+Scope

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2.0 Overview and Scope
The initiative, Elements in Transition of Care, defines the electronic communication and data elements necessary for clinical information exchange to support transfers of care between providers and to inform patients.

This Use Case addresses two scenarios. The first scenario focuses on the exchange of patient information between providers to accomplish a successful transition in care from one care environment to another. This includes transitions between acute, long-term care, nursing facility, rehabilitation facilitation, home healthcare, as well as discharges to home and the primary care provider encounter. Transitions within the same care setting are not included in the scope of this Initiative. The Use Case also includes referrals for the purpose of consultations.

The second scenario focuses on the sharing of electronic clinical information from providers to their patients, including the data interchange required to support the needs of a patient during these transitions of care and the capabilities necessary to support the exchange of the supporting clinical ``[template``] documentation. In this scenario, the patient has the ability to access and incorporate their available clinical information into their PHR.

For both scenarios, it is important to have common services-based transport standards for the secure and interoperable exchange of electronic health information in the context of Elements in Transition of Care.

Successful outcomes and metrics of this Use Case include:
 * 1) The number of providers sharing Transitions of Care summaries
 * 2) The number of organizations who have been certified to produce valid specifications (Software development/Tools organizations/Provider organizations)
 * 3) The time reduction for creation of a new minimal unstructured summaries and structured summaries
 * 4) Cost reduction for creation of core elements within Transitions of Care
 * 5) Improvement in ability to achieve MU criteria
 * 6) Process improvement efforts related to transfer patterns  in a health information technology environment
 * 7) Enhanced patient clinical outcomes secondary to self-awareness and involvement in their care
 * 8) Identifying best practice IT standards to promote the interoperability of systems to successfully exchange clinical information safely and securely and to enable the recipient to view the clinical information in a human readable format.

2.1 In Scope

 * Clinical Summary information and its basic dataset(s) for the Transition of Care to include the transfer of care and the exchange of clinical information between providers and between providers and patients
 * While all transitions between different care settings as discussed in the overview are to be supported over the longer term, the initial scope is focused on transitions necessary to support transitions from eligible providers, hospitals and critical access hospitals as defined in Meaningful Use rules for Stage 1. Additionally, the Use Case will give secondary priority to transition recommendations for Stage 2 Meaningful Use. The resulting requirements should provide a base for future support of additional transitions from other providers and organizations.

2.2 Out of Scope

 * The comprehensive EHR
 * Financial Information, except for basic insurance information, will not be sent
 * While Query Transactions are out of scope, consideration of metadata necessary to tag clinical summaries to support queries is within scope.
 * Sharing of clinical summaries for other purposes; e.g., claims submission

2.3 Background
The Transition of Care Initiative was selected because of its alignment with Meaningful Use Stage 1 and anticipated Stage 2 as well as addressing various Prioritization Criteria as described next.

The Transition of Care Initiative holds importance and relevance in that it addresses improvement in care coordination and engagement of patients and families in their healthcare; achieving Meaningful Use Stage 1 and further builds a strong foundation for the greater demands on performance of Meaningful Use Stage 2. Transition of Care also contributes to major initiatives such as Virtual Lifetime Electronic Record (VLER), Nationwide Health Information Network (NHIN), Accountable Care Organizations, Patient Centered Medical Home, Bundled Payment Models and are relevant to participating stakeholders.

The technical feasibility of this Initiative requires and supports information exchange. The Initiative specifically leverages existing interoperability standards; thus, many of Healthcare Information Technology Standards Panel (HITSP) specifications (Appendix B) apply as well as utilizing standards such as Health Level Seven (HL7) Continuity of Care Document (CCD and ASTM Continuity of Care Record (CCR)) developed by existing standard development organizations. Furthermore, it should be taken into account that Meaningful Use Stage 1 presents as an option that either the CCR or CCD could be utilized in the context of transition of care. The Initiative supports data flow which can be tested as exhibited by the fact that NIST has current test scripts available. Also, the Initiative contributes to overall cost savings within the US health system. The Transition of Care Initiative is accountable by aligning Stakeholders’ readiness level of use as well as attempting to improve general Health IT usability.

Finally, the Transition of Care Initiative supports various evidenced based medicine and research initiatives to include Comparative Effectiveness Research and other high priority research initiatives that align with ONC’s agenda.

These Prioritization criteria coupled with existing relevant Use Cases (Appendix A) have rendered the basis for selection of the Transition of Care Initiative; thus, leveraging lessons learned that will be applied to the formulation of this Use Case.

2.4 Policy Issues
The Use Case strives to address relevant and timely policy issues that will have downstream impacts on the US healthcare reform agenda; specifically as related to healthcare information technology.

The Affordable Care Act mandates multiple pilots involving coordination of care, particularly at transitions. The primary policy issue at hand is the intention of the HIT Standards Committee to converge the clinical summary into a single standard. The Standards Committee has not confirmed that the HITSP C32/CCD will be the Base Standard. The current rule allows both CCD and CCR to be adopted.

The CCR and CCD do not have sections for Discharge diagnosis; this potentially could be included in a transfer of care ``[summary``].

The User Story and Activity Diagrams represent a generalized flow of information exchange, but do not represent infrastructure, architecture, or workflow requirements. They show what information needs to go from place A to place B to achieve a clinically sound transfer of care for the patient; however, they dictate neither the information content format, nor the specific transactions for the transfer of this information. It is left to policy makers to determine what requirements are applied to eligible providers for transition of care.

2.5 Regulatory Issues
Implementation of the Transitions of Care Initiative supports the following regulatory requirements:

The Final Rule for Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology for Meaningful Use Stage 1 states the following:

//A. Initial Set of Standards, Implementation Specifications, and Certification for Electronic Health Record Technology (July 2010) identified the following standard for Engagement of Patients and Families in their Healthcare://

> //__**(1) Electronic Copy of Health Information:**__ Electronic copy of health information. Enable a user to create an electronic copy of a patient’s clinical information, including, at a minimum, diagnostic test results, problem list, medication list, and medication allergy list in: (1) Human readable format; and (2) On electronic media or through some other electronic means in accordance with: (i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used:// >> //**(A) Problems.** The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2);// >> //**(B) Laboratory test results.** At a minimum, the version of the standard specified in §170.207(c); and// >> //**``(C``) Medications.** The standard specified in §170.207(d) Electronic Copy of *Discharge Instructions: Electronic copy of discharge instructions enable a user to create an electronic copy of the discharge instructions for a patient, in human readable format, at the time of discharge on electronic media or through some other electronic means.//

> //__**(2) *Electronic Copy of Discharge Instructions:**__ Electronic copy of discharge instructions. Enable a user to create an electronic copy of the discharge instructions for a patient, in human readable format, at the time of discharge on electronic media or through some other electronic means.//

> //__**(3) Clinical Summaries for each Office Visit:**__ Clinical summaries enable a user to provide clinical summaries to patients for each office visit that include, at a minimum, diagnostic test results, problem list, medication list, and medication allergy list. If the clinical summary is provided electronically it must be: (1) Provided in human readable format; and (2) Provided on electronic media or through some other electronic means in accordance with: (i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used:// >> //**(1) Problems.** The standard specified in §170.207(a) (1) or, at a minimum, the version of the standard specified in §170.207(a) (2);// >> //**(2) Laboratory test results.** At a minimum, the version of the standard specified in §170.207(c); and// >> //**(3) Medications.** The standard specified in §170.207(d).//

//B. Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology (July, 2010) identified the following standard for Improvement in Care Coordination://

> //(1) Enable a user to create an electronic copy of a patient’s clinical information, including, at a minimum, diagnostic test results, problem list, medication list, medication allergy list, and procedures: (I) In human readable format, and (ii) on electronic media or through some other electronic means in accordance with: (A) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (B) For the following data elements the applicable standard must be used:// >> //**(1) Problems.** The standard specified in §170.207(a) (1) or, at a minimum, the version of the standard specified in §170.207(a) (2);// >> //**(2) Procedures.** The standard specified in §170.207(b) (1) or §170.207(b) (2);// >> //**(3) Laboratory test results.** At a minimum, the version of the standard specified in §170.207(c); and// >> //**(4) Medications.** The standard specified in §170.207(d).//

> //(2) Enable a user to create an electronic copy of a patient’s discharge summary in human readable format and on electronic media or through some other electronic means.//

2.6 Communities of Interest
Communities of Interest are public and private stakeholders that are directly involved in the business process or are involved in the development and use of interoperable implementation guides and in their actual implementation. Communities of Interest may directly participate in the exchange; that is they are business actors, or indirectly through the results of the improved business process.

The following list of Communities of Interest and their definitions are for discussion purposes for Clinical Information Exchange.
 * **Members of Communities of Interest** || **Working Definition** ||
 * Patient || Members of the public who require healthcare services from ambulatory, emergency department, physician’s office, and/or the public health agency/department. ||
 * Consumers || Members of the public that include patients as well as caregivers, patient advocates, surrogates, family members, and other parties who may be acting for, or in support of, a patient receiving or potentially receiving healthcare services. ||
 * Care Coordinators || Individuals who support clinicians in the management of health and disease conditions. These can include case managers and others. ||
 * Clinicians || Healthcare providers with patient care responsibilities, including physicians, advanced practice nurses, physician assistants, nurses, psychologists, pharmacists, and other licensed and credentialed personnel involved in treating patients. ||
 * Laboratories || A laboratory (often abbreviated lab) is a setting where specimens are sent for testing and analysis are resulted, and then results are communicated back to the requestor. The types of laboratories may include clinical/medical, and environmental, and may be both private and/or public ||
 * Pharmacies || Entities that exist that are experts on drug therapy and are the primary health professionals who optimize medication use to provide patients with positive health outcomes ||
 * Provider || An individual clinician in a care delivery setting who requests or accepts the transfer of the clinical summary for the purposes of delivering care ||
 * Provider Organizations || Organizations that are engaged in or support the delivery of healthcare to include Hospitals, Ambulatory Centers and Provider Practices. ||
 * Standards Organizations || Organizations whose purpose is to define, harmonize and integrate standards that will meet clinical and business needs for sharing information among organizations and systems ||
 * Federal Agencies || Organizations within the federal government that deliver, regulate or provide funding for health and health care ||
 * Electronic Health Record/Personal Health Record Vendors || Vendors which provide clinicians and consumers specific EHR/PHR solutions to such as software applications and software services. These suppliers may include developers, providers, resellers, operators, and others who may provide these or similar capabilities. ||



Previous Versions
__**Click on the version number in the table below to download the Word document for previous iterations of the Overview and Scope.**__
 * **Previous Versions** ||
 * [|v 0.1] ||
 * [|v 0.2] ||

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