ToC+-+Scenario+1+SWG

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**The ToC Use Case and Requirements Workgroup has completed its activities, and is no longer meeting on a regular basis. To view work completed as part of the Scenario 1 Sub-Workgroup, please reference the material below:**

**Purpose and Goals:** To complete the applicable diagrams, functional requirements and data set considerations that support Scenario 1: Provider to Provider.

Meeting Summaries:

 * **Meeting Date** || **Meeting Agenda** || **Meeting Summary** || **Date Posted** ||
 * 03/22/11 ||  || [|Meeting Summary] || 03/23/11 ||
 * 03/23/11 || [|Meeting Agenda] || [|Meeting Summary] || 03/23/11 ||
 * 03/24/11 || [|Meeting Agenda] || [|Meeting Summary] || 03/24/11 ||
 * 03/25/11 || [|Meeting Agenda] || [|Meeting Summary] || 03/25/11 ||
 * 03/28/11 || [|Meeting Agenda] || [|Meeting Summary] || 03/28/11 ||
 * 03/29/11 || [|Meeting Agenda] || [|Meeting Summary] || 03/30/11 ||

Participants:

 * **Name** || **Role** ||
 * Mayuri Patel || Co-Lead ||
 * Vassil Petychev || Co-Lead ||
 * Cindy Levy || Member ||
 * Elliott Sloane || Member ||
 * Greg Smith || Member ||
 * Holly Miller || Member ||
 * John Odden || Member ||
 * Larry Sampson || Member ||
 * Russell Leftwich, MD || Member ||
 * Steve Rushing || Member ||
 * Susan Campbell || Member ||


 * **Name** || **Size** || **Creator** || **Creation Date** || **Comment** ||
 * [|ONC_UCR_Scenario 1 Sub-WG meeting 03-22-11_Final.docx] || 32 kB || Amy Berk || Mar 23, 2011 ||  ||
 * [|UCRSubWorkgroupFunctReqScenario1.docx] || 15 kB || Amy Berk || Mar 23, 2011 ||  ||
 * [|ONC_UCR_Scenario 1 Sub-WG meeting 03-23-11_Final.docx] || 32 kB || Amy Berk || Mar 23, 2011 ||  ||
 * [|Coupled Processes.doc] || 31 kB || Amy Berk || Mar 23, 2011 ||  ||
 * [|ONC_UCR_Scenario 1 Sub-WG meeting 03-24-11_Final..docx] || 32 kB || Amy Berk || Mar 24, 2011 ||  ||
 * [|ScenarioSequenceDiagram.PNG] || 19 kB || Bob DeAnna || Mar 28, 2011 ||  ||
 * [|Scenario%201%20Activity%20Diagram%20-%202.PNG] || 23 kB || Bob DeAnna || Mar 28, 2011 ||  ||
 * [|ScenarioActivityDiagram.PNG] || 23 kB || Bob DeAnna || Mar 28, 2011 ||  ||
 * [|Definitions.pptx] || 37 kB || Amy Berk || Mar 24, 2011 ||  ||
 * [|Scenario1ClosedLoop.png] || 84 kB || Vassil Peytchev || Mar 29, 2011 ||  ||
 * [|Scenario1SequenceClosedLoop.png] || 51 kB || Vassil Peytchev || Mar 29, 2011 ||  ||
 * [|S1actiondiagramProvidertoProvider.png] || 32 kB || Mayuri Patel || Mar 29, 2011 ||  ||
 * [|S1ProvidertoProviderDischargeSummary.png] || 12 kB || Mayuri Patel || Mar 30, 2011 ||  ||
 * [|S1TOCPROVIDERTOPROVIDERSEQUENCEDIAGM.png] || 15 kB || Mayuri Patel || Mar 29, 2011 ||  ||
 * [|S1PROVIDER_TO_PROVIDER_ACTION_DIAGRAM_FINAL.png] || 54 kB || Mayuri Patel || Mar 30, 2011 || Final Action diagram for Story 1 ||
 * [|S1ProvidertoProviderDischargeSummarySequenceDiagramFinal.png] || 13 kB || Mayuri Patel || Mar 30, 2011 || Final sequence diagram for Story 1 ||

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.

 * The Exchange of Information to Support the Transfer of Patient Information from a One Provider to Another**


 * Assumptions**
 * 1) Receiving facility has provisionally accepted the patient for transfer or referral with patient consent and wants the clinical summary
 * 2) Negotiations between providers is out of band but necessary to assure acceptance of transfer or referral
 * 3) Agreement to receive by other provider and by patient is necessary for actual transfer or referral of patient
 * 4) Same assumptions apply from Scenario 2
 * 5) Scenario 1 does not describe transport or end user site activity.
 * 6) The Information exchange can be achieved with or without intermediaries. Using intermediaries should not create any new functional requirements for the exchange of information

**User Story 1: //See User Story developed by User Story Sub Workgroup on Hospital or ED discharge.//**

 * Actors**
 * **Actor** || **Details** ||
 * Source || Provider: Hospital or ED Clinical System ||
 * Destination || Provider: Patient's PCP or Care Team ||


 * Setting 1: Hospital or ED from where patient is discharged (sends discharge summary to PCP or Care Team).**

A patient is discharged from the hospital. 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 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 by one of the patient’s treating clinicians. The actual clinician is dependent on the hospital’s workflow and may be a resident, a hospitalist, an advanced practice nurse or the attending physician of record. Once the discharge summary is prepared, it is ready to be reviewed by the attending physician of record (APoR) (if it has not been prepared by the APoR).

The APoR reviews the discharge summary and, once he has approved it, the discharge summary is sent to the PCP. The message 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.

NOTE: The Discharge Instructions described above are also part of the discharge summary. If the discharge summary is ready at the time of physical discharge, it is the only document necessary to be sent to the PCP or patient's care team.

Audit logs of the exchange are retained according to the hospital's, PCP's, and any intermediary's policies, procedures, and agreements.


 * Setting 2: Patient's PCP or Care Team (receives discharge summary from Hospital or ED clinical system).**

Discharge summary/instructions are received into the PCP practice’s EHR system. Patient generally will be known in the EHR system in which case an automated EHR match may occur (for example, if the hospital and PCP systems can share a common patient identifier). Discharge summaries/instructions that are not automatically matched to a patient are reconciled manually, which may include the process of creating a new patient record and registering the patient. Once the discharge summary/instructions have become part of the PCP’s EHR system, additional practice variable activities may occur: new tasks may be directed to a front desk staff EHR work queue, as well as to additional staff EHR work queues as appropriate to the practice workflows. Followup/plan of care are managed according to established PCP workflow. For example, upon receiving notification of the patient’s status, the care manager is now aware that the patient becomes confused when medications are altered and calls the patient to ensure the patient is taking the correct medications post discharge and is following the discharge instructions.

The PCP may review and promote into the EHR the newly reconciled active medications, updated problem lists, new procedures and other discrete data elements. The hospital (or ED) discharge summary/instructions are retained in its entirety as a permanent part of the patient’s record.

**User Story 2: //See User Story developed by User Story Sub Workgroup on Closed Loop Referral.//**

 * Actors**
 * **Actors** || **Role** ||
 * Provider; PCP's EHR System || Referral Source ||
 * Provider; Specialist's EHR System || Referral Destination ||


 * Setting 1: PCP's office (sends referral request clinical summary to specialist).**

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 message is addressed to the appropriate specialist, specialty or provider organization and is sent to the specialist’s EHR system.


 * Setting 2: Specialist's office (receives referral request clinical summary from PCP; send consultation summary to PCP).**

The referral 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 consult summary to the PCP. Once the consult summary is prepared, it is addressed and sent to the PCP’s EHR system. A copy of the message is retained in the specialist’s EHR system.

11.1.1 Base Flow of Scenario 1
The original source for this event table was developed by the Use Case Simplification SWG.

User Story 1:

 * The Exchange of Discharge Summary to Support the Transfer of Patient Information from One Provider to Another**

(includes Discharge Instructions) || Discharge Instructions || Discharge Summary ||
 * **Step #** || **Actor** || **Event/Description** || **Inputs** || **Outputs** ||
 * 1 || Provider || Trigger Generation of Discharge Instructions for Patient A || START || Discharge Instructions ||
 * 2 || Hospital EHR System || Send Discharge Instructions to PCP's EHR System || Discharge Instructions || Discharge Instructions ||
 * 3 || PCP EHR System || Receive Discharge Instructions || Discharge Instructions || Discharge Instructions ||
 * ||  || **//Note: If the discharge summary is completed by the time the patient is physically discharged, then only the discharge summary (which includes the discharge instructions) needs to be sent to the PCP EHR system, thus making steps 2 and 3 unnecessary.//** ||   ||   ||
 * 4 || Provider || Trigger Generation of Discharge Summary for Patient A
 * 5 || Hospital EHR System || Send Discharge summary to PCP's EHR System || Discharge Summary || Discharge Summary ||
 * 6 || PCP EHR System || Receive Discharge Summary || Discharge Summary || Discharge Summary ||
 * 7 || Provider || View Discharge Summary/Instructions || Discharge Summary || END ||

User Story 2:

 * The Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient from One Provider to Another**


 * **Step #** || **Actor** || **Event/Description** || **Inputs** || **Outputs** ||
 * 1 || Provider || Trigger Generation of Referral Request Clinical Summary for Patient A || START || Generated Referral Request Clinical Summary ||
 * 2 || PCP EHR System || Send Referral Request Clinical Summary to specialist's EHR System || Referral Request Clinical Summary || Referral Request Clinical Summary ||
 * 3 || Specialist EHR System || Receive Referral Request Clinical Summary from PCP's EHR System || Referral Request Clinical Summary || Referral Request Clinical Summary ||
 * 4 || Provider || View Referral Request Clinical Summary in specialist's EHR System || Referral Request Clinical Summary || END ||
 * 5 || Provider || Trigger Generation of Consultation Summary for patient A || START || Generated Consultation Summary ||
 * 6 || Specialist EHR System || Send Consultation Summary to PCP's EHR System || Consultation Summary || Consultation Summary ||
 * 7 || PCP EHR System || Receive Consultation Summary from specialist's EHR System || Consultation Summary || Consultation Summary ||
 * 8 || Provider || View Consultation Summary in PCP's EHR System || Consultation Summary || END ||

11.1.2 Activity Diagram for Scenario 1
The following is the Activity Diagram to support the events in section 11.1.1.

The Exchange of Information to Support the Transfer of Patient Information from a One Provider to Another The Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient from One Provider to Another
 * User Story 1**:
 * User Story 2**:

11.2.1 Information Interchange Requirements of Scenario 1

 * **Initiating System** ||  || **Information Interchange Requirement Name** ||   || **Receiving/Responding System** ||
 * Hospital/ED EHR System || Send (A.XFER.1) || Discharge Summary || Receives (A.XFER.2) || PCP EHR System ||
 * PCP EHR System || Send (A.XFER.1) || Referral Request Clinical Summary || Receives (A.XFER.2) || Specialist EHR System ||
 * Specialist EHR System || Send (A.XFER.1) || Consultation Summary || Receives (A.XFER.2) || PCP EHR Systgem ||

11.2.2 System Requirements of Scenario 1

 * **System Requirement Name** || **System** ||
 * Display Discharge Summary || PCP EHR System ||
 * Display Referral Request Clinical Summary || Specialist EHR System ||
 * Display Consultation Summary || PCP EHR System ||

11.3 Sequence Diagrams
The following sequence diagrams describe the messages and order of messages.


 * User Story 1**:

The Exchange of Information to Support the Transfer of Patient Information from One Provider to Another
The Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient from a One Provider to Another
 * User Story 2**:

14.0 Data Set Considerations
**Please See Scenario 2 Data Set Considerations - this way they are documented in one place.**

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