Transitions+of+Care+Modular+Spec+Profile+-+Proposed

=Profile introduction=

This profile is designed to serve the needs of implementers who wish make use of the NwHIN protocols as a transport method for the four key information exchanges associated with the S&I Framework Transitions of Care Initiative. The approach utilized by the Transitions of Care Initiative was to reuse existing standards wherever possible, and in this initiative, CDA was chosen as the preferred platform to exchange clinical documentation. However, the guidance from the initiative as of yet does not define or recommend a transport method to be used by implementers. Additionally, privacy, security and information management requirements and guidance have not been provided to implementers to be applied to the implementation environment.

The approach for profile development through the S&I Framework is to provide non-prescriptive, informative guidance to implementers to meet that need. This profile represents the collective efforts of Transitions of Care Initiative and will be updated through subsequent versions to support on-the-ground feedback from pilot implementations and vendors who implement the information exchanges outlined through the Transitions of Care initiative.

This specific profile also provides a further level of constrained configuration choices where necessary in use of both CDA and the NwHIN protocols to ensure that they can be used in their respective domains in an integrated manner between different actors. The profile lays out an implementation path for those implementers who wish to exchange the Transition of Care clinical documents without being overly constraining in specifying transport, privacy, or security specifics, to allow for customization and optimization in support of specific environments. The deployment models outlined in the S&I Framework Transitions of Care Initiative should be reused wherever possible, and this profile further expands in more detail on how these deployment models can directly apply to implementation environments.

For more information on the NwHIN Modular Specification work (both Phase 1 and Phase 2), please visit and register for the Modular Specifications Wikispace.

Structure of this Profile
The profile establishes an implicit framework of actors, roles, and transactions that will need to be supported for a care transition information exchange. Transactions are identified within this profile that will need to be implemented in order to use NwHIN protocols as a transport mechanism for a care transition. Many of these transactions relate to the interaction of the actors and roles within a care transition. The profile also outlines specific information exchange flows that this profile would support, as well as security requirements associated with each of these flows.

Scope
Because of the broad scope of potential information exchanges that the NwHIN is designed to support, the scope of this profile is designed to cover specific transactions and content that are specific to a care transition from one NwHIN participant to another NwHIN participant, or to transactions that may occur from one NwHIN participant to a participant not currently connected to the NwHIN. The specific scope of this profile differs from other S&I Framework profiles in that it supports numerous architecture approaches that might be used by an Exchange partner. These include publish/subscribe, query/retrieve, and sending of information using a SOAP message. Ultimately the scope of the exchanges can increase depending on the evolving standards and NwHIN participant needs from state level exchanges, public health entities, IDNs, federal entities, to finally geographically-based health information organizations. =Profile use case alignment= The use cases applicable to this profile are drawn from the S&I Framework Transitions of Care Use Case. Specifically, this profile supports the following user stories:
 * **Exchange of Discharge Summary to Support the Transfer of Patient Information from One Provider to another Provider **
 * **Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient from One Provider to Another **
 * **Exchange of Information to Support the Transfer of Patient Information from a One Provider to Another **
 * **Exchange of Clinical Summaries to Support the Closed Loop Referral of a Patient from a One Provider to Another **

//**Addition needed: mapping of use case roles to information exchange participants**//

Actors and Transactions
The following table outlines the specific actors involved in the information exchanges between Information Receiver || Technical || The set of services that may be provided by an Exchange partner are outlined in the next section and this role encapsulates a broad set of potential services that could be provided by a Exchange Partner. =Services orchestration= This profile assumes a set of services are made available by the Exchange partner to support the needs of participants who may be interested in either sending or receiving care transition information. Many Exchange participants will already have many of these services in place, and in the context of this profile, these services are thus defined at a high level with the assumption that the Exchange participant has implemented them according to current Exchange specifications. A high-level view of the services needed are shown below:
 * **Actor Name** || **Potential Roles** || **Type of Actor** ||
 * Provider ||  || Business ||
 * Document Repository ||  || Technical ||
 * Document Registry ||  || Technical ||
 * EHR System || Information Source
 * Specialist ||  || Business ||


 * Record Locator
 * Master Patient Index
 * Document Submission
 * Query/Retrieve
 * Provider Directory
 * Payer Directory
 * Provider Portal (linked to Direct protocol)


 * Authorization Services
 *  Authentication Services
 *  Auditing Services


 *  Provider Discovery
 *  Patient Discovery


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 13.3333px;"> Document Query
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 13.3333px;"> Document Submission
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 13.3333px;"> Document Retrieval
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 13.3333px;"> Document Subscription

Modular Specification Transactions
A series of transactions are defined for this profile that are drawn directly from current Phase 1 Modular Specification development. including Clinical Summary ||  ||   || Summary ||  ||   || Summary ||  ||   || Summary ||  ||   || =Information Exchanges= This section outlines each of the information exchanges that the Direct profile can support. The guidance in this profile is intended to apply solely to these information exchanges, and while future work may allow for this profile to be expanded in support of other information exchanges for care transitions, the intention is that this profile supports only those key information exchanges defined in the S&I Framework Transitions of Care Use Case and in the harmonization of standards through the S&I Framework.
 * **Transaction Name** || **Description of Transaction** || **Prerequisites** ||
 * Assemble CDA Document ||  ||   ||
 * Attach CDA Document ||  ||   ||
 * Send Secure SOAP Message ||  ||   ||
 * Retrieve Document from Document Repository ||  ||   ||
 * Publish Document to Document Repository ||  ||   ||
 * Subscribe to Document Registry ||  ||   ||
 * Query Document Registry ||  ||   ||
 * Generate Discharge Summary ||  ||   ||
 * Generate Discharge Instructions ||  ||   ||
 * Generate Consultation Summary ||  ||   ||
 * Generate Consultation Request
 * Send Discharge Summary ||  ||   ||
 * Query and Retrieve Discharge Summary ||  ||   ||
 * Submit Discharge Summary ||  ||   ||
 * Send Discharge Instructions ||  ||   ||
 * Query and Retrieve Discharge Instructions ||  ||   ||
 * Submit Discharge Instructions ||  ||   ||
 * Send Consultation Request with Clinical
 * Submit Discharge Instructions ||  ||   ||
 * Send Consultation Request with Clinical
 * Send Consultation Request with Clinical
 * Query for Consultation Request with Clinical
 * Retrieve Consultation Request with Clinical
 * Send Consultation Summary ||  ||   ||
 * Query for Consultation Summary ||  ||   ||
 * Retrieve Consultation Summary ||  ||   ||
 * Submit Consultation Summary ||  ||   ||
 * Submit Consultation Summary ||  ||   ||

Constraints for Exchanges
This profile specifically does not specify at this time any profile-level constraints, such as transport, privacy, or security constraints. There are several reasons for this: The four information exchanges that this profile supports (and the specific system actors associated with each of these key information exchanges) are shown below:
 * Constraints for transport, security, and privacy are inherited from the Direct specification and should be used to form the foundational level of constraints for information exchange.
 * Constraints for the information exchanges (content) are inherited from the Transitions of Care Implementation Guidance, and from the underlying CDA standard.
 * Additional constraints can be defined by an implementer or vendor depending on the unique conditions of their implementation environment. Not all constraints can be captured in this profile.

Discharge Summary
The Discharge Summary is the clinical document used in the event that a patient is discharged from a healthcare provider, containing an overview of patient care information, such as demographic information, active reconciled medication list (with doses and sig), allergy list, problem list, and reason for admission. The document includes both a standard dataset and a discharge context relevant dataset, both of which are determined by the discharging provider organization in accordance with local policy, regulations and law. At discharge, the summary might include content for the Discharge Instruction as well as Discharge Summary.
 * **Sender:** EHR System (Hospital)
 * **Receiver:** EHR System (Primary Care Physician)

Discharge Instructions
The Discharge Instructions contains the dataset relevant to the Discharge Summary context, which includes follow up/plan of care. The Discharge Instructions may be generic, patient specific, or disease specific depending upon the facility’s practices and the patient’s needs. The document includes data relevant to the following sections: Plan of care, allergies/adverse reactions/alerts, problems list, hospital discharge medications, advance directions, immunizations, and medical equipment. The document is given to the patient by their nurse or care manager at or a short time before physical discharge and a copy is sent to the patient’s PCP or Care Team. The patient’s acknowledgement that they have received, understood, and agreed to follow the Discharge Instructions, triggers the actual physical discharge.
 * **Sender:** EHR System (Hospital)
 * **Receiver:** EHR System (Primary Care Physician)

Consultation Summary
The Consultation Summary is the document that contains information determined by the provider organization surrounding a consultation and consultation context-relevant data. When the PCP physician determines that the patient needs to be referred to a specialist, they prepare the Consultation Request within the EHR. It is addressed to the appropriate specialist, who in accordance with practice policies and workflow, reviews the document and orders any additional tests to be performed for the patient prior to the office visit. The Consultation summary should always include a basic set of information on the consultation that might also include content for the Clinical Instruction as well as the Consultation Summary. Consultation summary content examples include demographic information, active reconciled medication list (with doses and sig), allergy list, problem list and variable data relevant to the context of the request.
 * **Sender:** EHR System (Primary Care Physician)
 * **Receiver:** EHR System (Specialist)

Consultation Request Including Clinical Summary
This information exchange would contain a standard set of data surrounding a consultation, and consultation context-relevant data, which is determined by the provider organization in accordance with local policy, regulations and law. The receiving provider through its EHR system may determine how to incorporate and present the Consultation Summary document. The Clinical Summary is an after-visit summary document that may contain variable data relevant to the context of the request. In addition, this information exchange also includes a PCP-selected referral-specific variable dataset. It can include any of the following items: Patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms. The Clinical Summary is addressed and sent to the PCP’s EHR as well as the patient’s PHR. =Information Exchange Flows=
 * **Sender:** EHR System (Hospital)
 * **Receivers:** EHR System (Primary Care Physician) AND/OR PHR System (Personal Health Record)

This section captures the information exchange flows, including orchestration of the transactions needed to support the exchange of information using NwHIN protocols. This is the basis for the profile and shows the interaction and orchestration of the transactions, roles, and actors defined within this profile.

Provider to Provider using HIE or Other Intermediary
The following scenario describes a normal information exchange flow using NwHIN Protocols to send a secure email message to another provider. This diagram outlines the exchange of a discharge summary to support the transfer of patient information from one provider to another provider, with the transfer of information occurring through a secure email message.

Provider to Specialist using HIE or Other Intermediary (sample)
=Alternative Information Exchange Flows (Samples)=

Subscribe to Care Transition Document
= = =Policy requirements= To be aligned with the policies outlined in the TOC Policy and Service Analysis wiki page

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