ToC+-+Scenario+2

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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, Scenario 2 is now 11.0 instead of 12.0 because of the deletion of the separate User Story section.**

11.1 User Stories of Scenario 2

 * The visuals below depict a combination of all events described in the scenario flows which are described in further detail in the tables that follow.**

**//(Refer to sections highlighted in red and italicized, that are the focus of this scenario)//**


 * Assumptions:** Scenario 2 does not describe transport or end user site activity.


 * User Story 1: The Exchange of Discharge Instructions and Discharge Summary between a Provider and Patient to Support the Transfer of a Patient from One Care Setting to Another.**


 * Actors**
 * **Actor** || **Details** ||
 * Provider: Any Provider EHR System || Source ||
 * Patient: The Patient's PHR System or Patient Portal || Destination ||
 * Setting 1: Hospital or ED from where patient is discharged (sends discharge instructions to patient).**

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 PHR// and 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. //The discharge summary may also be sent to the patient’s PHR system.//

__ **NOTE: The discharge instructions described above are also part of the discharge summary. Depending on the workflow, and the policies at the hospital or ED, the patient and patient’s PHR may receive only the discharge instructions at discharge. The discharge summary may be provided later upon request and within 36 hours of discharge.** __

Audit logs of the exchange are retained according to the hospital’s, PHR systems, and any intermediaries’ policies, procedures, and agreements.


 * Setting 2: Patient**

//The patient discharge instructions and discharge summary are received by the patient’s PHR system. Depending on the specific PHR application, the patient or home health agency (HHA) receives a notification to access and review the PHR. The patient (or patient’s authorized proxy) accesses the PHR and may review the patient discharge instructions. Again, depending on the PHR system's functionality the patient or proxy may be able to select sections within the discharge instructions (discrete data elements) to automatically populate the appropriate fields in the PHR. For example, the newly reconciled medication list is selected to upload to the active medication list section of the PHR and the patient uploads any new problems to the problem list. Some information may be selected to initiate the agency workflow process. Some PHR systems may have “all or none” functionality allowing the patient to determine if he would like to either retain or delete the discharge instructions from the PHR.//

//The PHR system may also receive the discharge summary. In that case please see the "Closed Loop Referral" User Story about handling the receipt of a medical summary in the PHR system.//


 * User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the Closed-loop Transfer of a Patient from One Care Setting to Another Consultation Referral.**


 * Actors**
 * **Actor** || **Role** ||
 * Provider: Any Provider EHR System || Source ||
 * Patient: The Patient's PHR System or Patient Portal || Destination ||
 * Setting 1: PCP’s office**


 * Activity**: Primary Care Physician 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 summary is addressed to the appropriate specialist, specialty or provider organization and is sent to the specialist’s EHR system.

**//The consultation request clinical summary may also be sent to the patient’s PHR system.//**


 * Setting 2: Specialist’s office**


 * Activity:** The referral 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 to the PCP. Once the consultation summary is prepared it is addressed and is sent to the PCP’s EHR system. A copy of the summary is retained in the specialist’s EHR system.

**NOTE: The return to PCP office is only needed in Scenario 1 for the receiving of the consultation summary by the PCP. In Scenario 2 there is not provider/patient exchange of information as part of Transition of Care in the return to Setting 1.**

**//The consultation summary may also be sent to the patient’s PHR system.//**


 * Setting 3: Patient**


 * Activity: //"Consultation request clinical summary” is received by the patient’s PHR system.// ** //Depending on the specific PHR system, the patient may receive a notification to access his PHR as there is new information available. The patient (or the patient’s authorized proxy) accesses the PHR and may review the consultation request clinical summary. The patient (or his proxy) may respond with questions. Again, depending on the PHR system's functionality the patient may be able to select sections of the consultation request clinical summary (that are discrete data elements) to automatically populate the appropriate fields in the PHR. For example, the patient may upload any new problems to the problem// //list. Other PHR systems may have “all or none” functionality allowing the patient to simply determine if he would like to retain or delete the consultation request clinical summary in the PHR system.//


 * Activity: //"Consultation summary" is received by the patient’s PHR system.// ** //Depending on the specific PHR system, the patient may receive a notification to access their PHR as there is new information available. The patient (or the patient’s authorized proxy) accesses the PHR and may review the// **//specialist’s consultation summary////.//** //The patient (or his proxy) may respond with questions. Again, depending on the PHR system's functionality the patient may be able to select sections within the// **//consultation summary//** //(that are discrete data elements) to automatically populate the appropriate fields in the PHR. For example, the patient can upload any new problems to the problem list.// //Other PHR systems may have “all or none” functionality allowing the patient to simply determine if he would like to retain to or delete the consult summary in the PHR system.//

**11.1.1 Base Flow of Scenario 2**

 * User Story 1: The Exchange of Discharge Instructions and Discharge Summary between a Provider and Patient to Support the Transfer of a Patient from One Care Setting to Another.**


 * **Step #** || **Actor** || **Event/Description** || **Inputs** || **Outputs** ||
 * **1** || **Provider** || **Order/Address/Request: Discharge Summary and Discharge Instructions to Patient A in EHR (and has been acknowledged by patient)** || **START** || **Discharge Summary and Discharge Instruction Request** ||
 * **2** || **EHR System** || **Generate and Send: Discharge Instructions to PHR** || **Discharge Instructions Request** || **Discharge Instructions** ||
 * **3** || **PHR System** || **Receive: Discharge Instructions in PHR** || **Discharge Instructions** || **Discharge Instructions** ||
 * **4** || **EHR System** || **Generate and Send: Discharge Summary to PHR** || **Discharge Summary Request** || **Discharge Summary** ||
 * **5** || **PHR System** || **Receive: Discharge Summary in PHR** || **Discharge Summary** || **END** ||


 * User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the Closed-loop Consultation Referral.**
 * **Step #** || **Actor** || **Event/Description** || **Inputs** || **Outputs** ||
 * 1 || Provider (PCP) || Order/Address/Request: Consultation request while meeting with patient || START || Initiated Consultation Request ||
 * 2 || EHR System || Generate and Send: Consultation request summary || Initiated Consultation Request Summary || Consultation Request Summary ||
 * 3 || PHR System || Receive: Consultation Request Summary in PHR || Consultation Request Summary || Consultation Request Summary ||
 * ||  || **//Note: rows 4-6 will occur for any delivery of a Clinical Summary//** ||   ||   ||
 * 4 || Provider || Order/Address/Request: Clinical Summary including specialist’s summary || START || Initiated Clinical Summary Request ||
 * 5 || EHR System || Generate and Send: Clinical Summary details || Initiated Clinical Summary Request || Clinical Summary ||
 * 6 || PHR System || Receive: Clinical Summary in PHR || Clinical Summary || Clinical Summary ||

**11.1.2 Activity Diagrams for Scenario 2**
The following are the Activity Diagrams that support the events in section 11.1.1.


 * User Story 1: The Exchange of Discharge Instructions and a Discharge Summary between a Provider and a Patient to Support the Transfer of a Patient from One Care Setting to Another.**


 * User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the Closed-loop Consultation Referral.**

**11.2.1 Information Interchange Requirements of Scenario 2**

 * **Initiating System** ||  || **Information Interchange Requirement Name** ||   || **Receiving/Responding System** ||
 * Electronic Health Record System || Send (A.XFER.1) || Discharge Summary || Receives (A.XFER.2) || Personal Health Record System ||
 * Electronic Health Record System || Send (A.XFER.1) || Discharge Instructions || Receives (A.XFER.2) || Personal Health Record System ||
 * Electronic Health Record System || Send (A.XFER.1) || Consultation Request Summary || Receives (A.XFER.2) || Personal Health Record System ||
 * Electronic Health Record System || Send (A.XFER.1) || Clinical Summary || Receives (A.XFER.2) || Personal Health Record System ||

**11.2.2 System Requirements of Scenario 2**

 * **System Requirement Name** || **System** ||
 * Display Discharge Summary || Personal Health Record System ||
 * Display Discharge Instructions || Personal Health Record System ||

11.3 Sequence Diagrams
The following sequence diagrams describe the messages and order of messages.
 * User Story 1: The Exchange of Discharge Message (Discharge Instructions and Discharge Summary) to Support the Transfer of a Patient from One Care Setting to Another.**


 * User Story 2: The Exchange of Clinical Summaries between Provider and Patient to Support the Closed-loop Consultation Referral**

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