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Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Longitudinal Coordination
of Care Initiative
Elements in Transitions of Care and Plan of Care
for LTPAC Use Case
5/21/2012
1
2
TBD 1
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 Version Control
Date Version Owner Source Description of Changes
3/26/2012 v.01 UCR Support ToC Use Case V1.1 Add LCC ToC and PoC
Team and with LTPAC information and scenarios for
ToC and PoC first draft of document.
updates
4/18/2012 v.02 UCR Support Workgroup Revised to reflect the
Team Scoping consensus scope and related
Sections Discussions language throughout
1–5 established on 4/12 at the LCC
Only Face to Face Meeting
5/2/2012 v.03 UCR Support Workgroup Revised to reflect the edits
Team revising sessions from WG members on
sections 1-9
2
3
TBD 2
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 Table of Contents
2 List of Figures ................................................................................................................................................ 4
3 List of Tables ................................................................................................................................................. 4
4 1.0 Preface and Introduction ........................................................................................................................ 6
5 2.0 Overview and Scope................................................................................................................................ 6
6 2.1 In Scope ............................................................................................................................................... 8
7 2.2 Out of Scope........................................................................................................................................ 8
8 2.3 Background ......................................................................................................................................... 8
9 2.4 Policy Issues ...................................................................................................................................... 11
10 2.5 Regulatory Issues .............................................................................................................................. 12
11 2.6 Communities of Interest ................................................................................................................... 15
12 3.0 Challenge Statement ............................................................................................................................. 17
13 4.0 Value Statement ................................................................................................................................... 18
14 5.0 Use Case Assumptions .......................................................................................................................... 19
15 6.0 Pre-Conditions....................................................................................................................................... 20
16 7.0 Post Conditions ..................................................................................................................................... 21
17 8.0 Actors and Roles ................................................................................................................................... 21
18 9.0 Use Case Diagram ................................................................................................................................. 23
19 10.0 Scenario 1: The Exchange of Clinical Summaries from Provider to Provider...................................... 25
20 10.1 User Stories of Scenario 1 .............................................................. Error! Bookmark not defined.17
21 10.1.1 Base Flow of Scenario 1 .......................................................... Error! Bookmark not defined.21
22 10.1.2 Activity Diagrams for Scenario 1 ............................................. Error! Bookmark not defined.23
23 10.2 Functional Requirements of Scenario 1 ......................................... Error! Bookmark not defined.25
24 10.2.1 Information Exchange Requirements of Scenario 1 ............... Error! Bookmark not defined.25
25 10.2.2 System Requirements of Scenario 1 ....................................... Error! Bookmark not defined.25
26 10.3 Sequence Diagrams of Scenario 1.................................................. Error! Bookmark not defined.26
27 11.0 Scenario 2: The Exchange of Clinical Summaries between Provider to Patient in Support of
28 Transitions of Care ..................................................................................... Error! Bookmark not defined.28
29 11.1 User Stories of Scenario 2 .............................................................. Error! Bookmark not defined.28
30 11.1.1 Base Flow of Scenario 2 .......................................................... Error! Bookmark not defined.30
31 11.1.2 Activity Diagrams of Scenario 2 .............................................. Error! Bookmark not defined.32
32 11.2 Functional Requirements of Scenario 2 ......................................... Error! Bookmark not defined.34
33 11.2.1 Informational Interchange Requirements of Scenario 2 ........ Error! Bookmark not defined.34
34 11.2.2 System Requirements of Scenario 2 ....................................... Error! Bookmark not defined.34
35 11.3 Sequence Diagrams of Scenario 2.................................................. Error! Bookmark not defined.35
TBD 3
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 12.0 Issues and Obstacles .......................................................................... Error! Bookmark not defined.37
2 13.0 Dataset Considerations ...................................................................... Error! Bookmark not defined.37
3 APPENDICES ................................................................................................................................................ 52
4 Appendix A: Related Use Cases............................................................................................................... 52
5 Appendix B: Previous Work Efforts Related to Clinical Information Exchange ...................................... 52
6 Appendix C: Privacy and Security Assumptions ...................................................................................... 53
7 Appendix D: Glossary .............................................................................................................................. 53
8 Appendix E. References .......................................................................................................................... 56
9
10 List of Figures
11 Figure 1: Use Case Diagram ........................................................................................................................ 23
12 Figure 2: Context Diagram .......................................................................................................................... 24
13 Figure 3: Activity Diagram of Scenario 1 User Story 1 ............................... Error! Bookmark not defined.23
14 Figure 4: Activity Diagram of Scenario 1 User Story 2 ............................... Error! Bookmark not defined.24
15 Figure 5: Sequence Diagram of Scenario 1 User Story 1............................ Error! Bookmark not defined.26
16 Figure 6: Sequence Diagram of Scenario 1 User Story 1............................ Error! Bookmark not defined.27
17 Figure 7: Activity Diagram of Scenario 2 User Story 1 ............................... Error! Bookmark not defined.32
18 Figure 8: Activity Diagram for Scenario 2 User Story 2 .............................. Error! Bookmark not defined.33
19 Figure 9: Sequence Diagram for Scenario 2 User Story 1 .......................... Error! Bookmark not defined.35
20 Figure 10: Sequence Diagram of Scenario 2 User Story 2.......................... Error! Bookmark not defined.36
21 List of Tables
22 Table 1: Communities of Interest ............................................................................................................... 17
23 Table 2: Actors and Roles of Use Case ........................................................................................................ 22
24 Table 3: Actors and Roles for Scenario 1 User Story 1............................... Error! Bookmark not defined.17
25 Table 4: Actors and Roles for Scenario 1 User Story 2............................... Error! Bookmark not defined.19
26 Table 5: Base Flow of Scenario 1 User Story 1 ........................................... Error! Bookmark not defined.22
27 Table 6: Base flow of Scenario 1 User Story 2 ........................................... Error! Bookmark not defined.22
28 Table 7: Information Exchange Requirements of Scenario 1 .................... Error! Bookmark not defined.25
29 Table 8: System Requirements of Scenario 1 ............................................ Error! Bookmark not defined.25
30 Table 9: Actors and Roles of Scenario 2 User Story 1 ................................ Error! Bookmark not defined.28
31 Table 10: Actors and Roles of Scenario 2 User Story 2 .............................. Error! Bookmark not defined.29
32 Table 11: Base Flow of Scenario 2 User Story 1 .......................................................................................... 34
33 Table 12: Base Flow of Scenario 2 User Story 2 ......................................... Error! Bookmark not defined.31
TBD 4
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 Table 13: Informational Exchange Requirements of Scenario 2 User Story 1 ............................................ 36
2 Table 14: System Requirements of Scenario 2 .......................................... Error! Bookmark not defined.34
3 Table 15: Dataset for Discharge Instructions ............................................. Error! Bookmark not defined.40
4 Table 16: Dataset for Discharge Summary................................................. Error! Bookmark not defined.44
5 Table 17: Dataset for Clinical Summary ..................................................... Error! Bookmark not defined.49
6 Table 18: Dataset for Clinical Summary for Consultant Notes .................. Error! Bookmark not defined.54
7
8
TBD 5
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 1.0 Preface and Introduction
2 To fully realize the benefits of health IT, the Office of the National Coordinator for Health Information
3 Technology (ONC), as part of the Standards and Interoperability (S&I) Framework is developing Use
4 Cases that define the interoperability requirements for high priority health care data exchange;
5 maximize efficiency, encourage rapid learning, and protect patients’ privacy in an interoperable
6 environment. These Use Cases address the requirements of a broad range of Communities of Interests
7 including; patients, their significant others and family members, providers, vendors, standards
8 organizations, public health organizations, and Federal agencies.
9 These Use Cases describe:
10 The operational context for the data exchange
11 The stakeholders with an interest in the Use Case
12 The information flows that must be supported by the data exchange
13 The types of data required in the data exchange
14 The Use Case is the foundation for identifying and specifying the standards required to support the data
15 exchange and developing reference implementations and tools to ensure consistent and reliable
16 adoption of the data exchange standards.
17 2.0 Overview and Scope
18 This Use Case, Longitudinal Coordination of Care, defines a baseline for electronic communication and
19 data elements necessary for clinical information exchange to support longitudinal coordination of care
20 (LCC), transitions of care (ToC) and instances of shared care (SC) between providers in Acute Care sites
21 and Long-Term and Post-Acute Care (LTPAC) sites; and to inform patients, caregivers and delegates and
22 keep them involved in the management of their care.
23 The LCC Baseline Use Case uses the former Transitions of Care Initiative Use Case V1.1 as a starting point
24 from which to extend concepts, requirements and data relevant to the longitudinal coordination of care.
25 The LCC Workgroup will develop a White Paper (WP) to describe in detail the overall vision for LCC
26 health information interoperability including goals, objectives, activities and a timeline. The LCC WP will
27 describe the strategy for providing use case and implementation guidance to the LCC implementation
28 community. The WP will also describe a vision for the Care Plan and recommend a set of activities that
29 the LCC WG, standards organizations and FACAs will undertake over the next several months and years
30 to achieve the vision set out in the WP. The LCC Baseline Use Case and Use Case extensions to follow will
31 focus on the information required for organizations to evaluate and implement the specific exchanges
32 described in the Use Cases. The WP will be used to develop and update the vision, goals and objectives
33 of the LCC WG and how those goals serve the needs of the broader LCC community.
34 Longitudinal coordination of care will require continuous access by all relevant participants to a
35 standardized care plan that accurately reflects the patient’s status at any given time. The Baseline Use
36 Case provides implementers with guidance on the exchange care summaries, care consultations and a
37 plan of care between independent care providers and the patient.
38 The LCC Baseline Use Case extends the ToC Use Case into the complex information exchange
39 requirements for persons who receive long-term post-acute care. In addition, the LCC Baseline Use Case
TBD 6
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 extends beyond additional Transitions of Care requirements to an initial set of Plan of Care
2 requirements based on the components found in the Home Health Plan of Care (former CMS 485 form).
3 The Use Case describes “transitions of care” as an overarching concept that encompasses “transfers of
4 care summary”, “consultation request clinical summary” and “shared care encounter summary”. The
5 Use Case employs the phrase “Transitions of Care” when broadly referring to any transaction that
6 facilitates a permanent or temporary transfer.
7 With this in mind, the Use Case is comprised of 4 Scenarios:
8 1. Scenario 1: Provider to Provider data exchanges for Transfer of Care and Referral that support
9 the following interactions:
10 a. Acute Care Hospital to LTPAC site (Transfer of Care Summary);
11 b. LTPAC Site to Emergency Department/ Consultant (Consultation Request Clinical
12 Summary);
13 c. Emergency Department/ Consultant to LTPAC Site (Shared Care Encounter Summary).
14 2. Scenario 2: Provider to Provider data exchanges for the Home Health Plan of Care (HH-POC)
15 including the following user stories:
16 a. HH-POC (Initial and Recertification): Home Health Agency (HHA) to Physician, Physician
17 to HHA;
18 b. Interim Changes to HH-POC: HHA to Physician, Physician to HHA.
19 3. Scenario 3: Provider to Patient data exchanges that provide a copy of the provider to provider
20 data to the patient/ delegate for the Transitions of Care data exchanges described in Scenario 1.
21 4. Scenario 4: Provider to Patient data exchanges that provide a copy of the provider to provider
22 data to the patient/ delegate for the Home Health Plan of Care data exchanges described in
23 Scenario 2.
24 Scenario 1 – Provider to Provider Transitions of Care Baseline Transactions focus on the exchange of
25 patient information between multi-disciplinary teams of providers across acute and post- acute care
26 sites to support care coordination, management, and service delivery by ensuring that needed clinical
27 information is received (when authorized) by the multiple providers involved in a patient’s care and
28 supports safe and effective transitions in care from one care environment to another. These
29 transactions are meant to provide a generic LTPAC data set, which will be based on the requirements
30 defined for Home Health Agencies (HHAs) or Nursing Facilities (NFs) depending on the user story. The
31 LCC WG has determined that using HHAs and NFs as the initial sites to inform the generic LTPAC
32 transition will provide a high degree of overlap and utility with other LTPAC sites, e.g. Inpatient
33 Rehabilitation Facilities (IRFs). This Use Case includes referrals for the purpose of consultation; however,
34 transitions within the same care setting are not included in the scope of this Initiative. Because of CMS
35 mandates for standardized assessment tools for HHAs and Nursing Facilities, the OASIS C and MDS 3.0
36 respectively, most LTPAC sites already collect and transmit electronically some clinical information. Re-
37 using the data elements captured in these reporting instruments to improve transitions and longitudinal
38 coordination of care is an important strategy and requires standardization of data elements and
39 interoperability across all sites of care. Last, it is important to note that the LTPAC to ED and Ed to LTPAC
40 transactions are intended to represent a generic consultation, so there is no admission and therefore no
41 discharge included in that user story.
42 Scenario 2 – Home Health Plan of Care: These transactions focus on the sharing of electronic clinical
43 information between HHAs and the physician signing orders for the patient. This represents a frequent
44 data interchange between HHA and Physician, including the signing and authorization of the plan, in a
TBD 7
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 circumstance where the patient lives at home. The CMS OASIS C reporting instrument will be evaluated
2 to determine which elements can be leveraged to generate the Home Health POC.
3 Scenarios 3 and 4 - Acute and LTPAC Provider to Patient: These transactions focus on the sharing of
4 electronic clinical information from Acute Care Hospitals and LTPAC providers to their patients, including
5 the data interchange required to support the needs of a patient during transitions of care, and/or to
6 keep the patient/consumer/ delegate (e.g., family member) informed of the patient’s status. In this
7 scenario, the patient has the ability to access and incorporate their available clinical information into
8 their PHR. The emphasis in Scenario 3 is on patients transferred to or from LTPAC sites of care as well as
9 the Home Health Plan of Care that is utilized to manage a patient’s care while receiving HHA services.
10 For all four scenarios, it is important to have common HIE transport standards for the secure and
11 interoperable exchange of electronic health information needed to support shared care, care planning,
12 and transfers in care. Furthermore, the data elements themselves must be defined, collected and
13 interpreted similarly across all care sites.
14 Success metrics for this Use Case will be developed closer to the time pilots are launched and will
15 leverage the ToC Success Metrics defined by the ToC Success Metrics Sub Workgroup.
16 2.1 In Scope
17 Clinical Summary information and its basic dataset(s) for the Transition of Care to include the
18 transfer of care and the exchange of clinical information between providers and between
19 providers and patients.
20 The Home Health Plan of Care information and its basic data sets necessary to perform the
21 initial, interim and recertification functions in the HHA setting and to inform patients and care
22 givers of patient status and medical course updates.
23 For the purposes of this Use Case, LTPAC transactions will be based on the data requirements
24 defined by the HHA or Nursing Facility trading partners depending on the specific user story.
25 2.2 Out of Scope
26 The comprehensive EHR
27 Financial Information, except for basic insurance information, will not be sent
28 While Query Transactions are out of scope, consideration of metadata necessary to tag clinical
29 summaries to support queries is within scope.
30 Sharing of clinical summaries for other purposes; e.g., claims submission
31 Transmission protocols are out of scope since the providers would not need to address the
32 transport, though the system itself (outside the scope of a use case) would have to address the
33 most efficient means of transport from sender to receiver.
34 Transitions within the same care setting (i.e. within the same legal organization)
35 Defining or modifying existing clinical medicine practices
36 Definition of requirements and data sets for Patient Assessment Summary Documents (PASDs) is
37 out of scope. The Keystone Beacon project can be referenced for the detailed requirements for
38 PASDs and the S&I Harmonization team is conducting an analysis of how this instrument
39 compares to the current standards.
40 2.3.1 General Background
41 Information exchange to support the a broad array of Health Transitions of Care is essential to
42 healthcare reform because its implementation will contribute to the overall cost savings within the US
TBD 8
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 health system through enhanced care coordination, improved clinical outcomes and care efficiency, and
2 decreased adverse events. This Use Case is expected to support the development of key elements of the
3 Nationwide Health IT Infrastructure as required in HITECH by enabling the electronic exchange and use
4 of health information needed to support quality and coordination of, and efficiencies in care as
5 individuals transition across health care settings and experience care that is shared across multiple
6 health care providers. This Use Case is aligned closely with the goals of Meaningful Use Stage 1 and the
7 Meaningful Use Stage 2 NPRM which has begun to recognize the need to include LTPAC settings
8 particularly in the context of the Care Coordination objective. The requirements defined in this Use Case
9 will inform the deliberations relative to Meaningful Use Stage 3 recommendations in both the Health
10 Information Technology Policy Committee and Health Information Technology Standards Committee.
11 Furthermore, the data exchange capabilities defined in this Use Case support evidence-based medicine
12 and research initiatives including Comparative Effectiveness Research and other high priority research
13 initiatives that align with the Nation’s agenda to improve the quality and coordination of care while
14 reducing its costs.1
15 While the scope of the Baseline LCC Use Case does not include requirements for the Patient Assessment
16 Summary Documents, it is important to recognize the importance of Patient Assessments and PASDs.
17 The Patient Assessment and PASD will be a likely source used to derive the information that will
18 populate the transactions that are described in this Use Case. Further the PASD will be a potential
19 solution for exchanging information.
20 The December 2011 LTPAC paper from AHIMA sites the following advantages of using Patient
21 Assessment information for clinical purposes, based on expert opinions:
22 “Exchanging patient assessment information could improve communication between care
23 providers and provides an important snapshot of an individual’s clinical status at the time the
24 assessment was completed.
25 Exchanging a summary of the patient’s clinical status derived from each assessment completed
26 provides allows for tracking and trending changes in condition over time and is useful to
27 clinicians and case managers.
28 Exchanging a summary of an assessment completed prior to transition may be dated but still
29 provides valuable information since some information is better than no information.
30 Re-using some assessment content could provide clinically useful information to support more
31 complex shared care and transition processes.”2
32
33 This Use Case extends the ToC V1.1 improvements in care coordination and patient engagement in their
34 own healthcare, in order that the strong foundation of Meaningful Use Stages 1 and 2 can be further
35 strengthened with the requirements developed for Meaningful Use Stage 3. Advancing the exchange of
36 transfer of care and referral documents and care plans that evolve as a result of exchanges between
37 organizationally unaffiliated providers (physicians and HHAs) will lay a strong foundation for supporting
38 the specification of vocabulary and document exchange standards that will be needed for longitudinal
1
Comparative Effectiveness Research (CER) evaluates existing health care interventions to determine which work
best for a particular patient as well as which treatments might have a deleterious effect and under what
circumstances they are most likely to cause the greatest harm. According to the Institute of Medicine, “CER assists
consumers, clinicians, purchasers, and policy makers in making informed decisions that will improve health care at
both the individual and population levels."
2
Michelle Dougherty and Jennie Harvell, “Opportunities for Engaging Long-Term and Post-Acute Care Providers in
Health Information Exchange Activities,” (American Health Information Management Activities 2011) 2-3.
TBD 9
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 care plan which will cross multiple sites of care, involve multiple disciplines and require iterative
2 exchanges among participants including the patient.
3 The technical feasibility of this Initiative requires and supports information exchange. The LCC Use Case
4 specifically leverages existing interoperability standards; thus, many of the Healthcare Information
5 Technology Standards Panel (HITSP) specifications (Appendix B) apply, as well as using standards such as
6 Health Level Seven (HL7) Continuity of Care Document (CCD) (which was produced as the result of an
7 MOU between two Standards Development Organizations and leveraged standards advanced by these
8 organizations, - the HL7 CDA and ASTM Continuity of Care Record (CCR)) and the HL7 CDA
9 Implementation Guide for Patient Assessment Questionnaires. These foundational documents have all
10 been considered in the development of the Consolidated CDA (C-CDA) templates that provide
11 implementation guidance for the CCD and Discharge Summary among other documents. The LCC Use
12 Case intends to align with the C-CDA, in particular, because the Meaningful Use (MU) Stage 2 Notice of
13 Proposed Rule-making (NPRM) identifies C-CDA as the applicable standard for summary and discharge
14 documents3.
15 In summary, the LCC Use Case draws heavily from the ToC V1.1 Use Case, intends to align with known
16 standards and identifies the data elements necessary for effective transitioning and planning in the
17 LTPAC environment.
18 2.3.2 Background Specific to the Home Health Plan of Care
19 The Home Health provider provides services to the patient as ordered by the physician. Throughout the
20 episode of Home Health, the Home Health provider and the physician exchange information about the
21 patient’s evolving condition and needs, and the services that the Home Health provider will perform. For
22 Home Health Agencies, the Centers for Medicare and Medicaid Services (CMS) has specified the content
23 of this exchange in the based on the former 485 form (see example in Appendix F).
24 When the physician refers the patient for Home Health, he/she provides current medical information
25 and general orders for Home Health. The HHA provider, by regulation, is required to perform a
26 comprehensive assessment, completing the OASIS as established by CMS and additional items to create
27 a comprehensive assessment. The assessment addresses the patient’s medical condition, functional
28 limitations in Activities of Daily Living (ADL), physical home environment, availability of in-home support
29 from family members or other caregivers, and other factors. The assessment process also includes a
30 complete inventory of all of the prescribed, over-the-counter, and herbal and biological medications the
31 patient is taking in the home, which the nurse or therapist reviews and reconciles with the physician; a
32 reconciliation of the patient’s allergies to medications, foods, and the environment; and an evaluation of
33 the patient’s mental status, including screening for depression. Based on this comprehensive
34 assessment, the nurse or therapist reconciles a plan of services and goals with the patient, and a service
35 regimen with the physician The service regimen specifies the frequency of visits by each Home Health
36 discipline (nursing, rehab therapy, social work, etc.) and the duration (in weeks) of such services; the
37 Durable Medical Equipment (DME) that the Home Health provider should furnish to the patient; and any
38 specialized types of treatment, such as specific wound care.
39 The Home Health Agency provider sends a summary of this assessment and treatment plan to the
40 physician as the HH-POC. The physician reviews this against the information in the patient’s chart,
3
Office of the National Coordinator for Health Information Technology (ONC), Department of Health and Human
Services, “Health Information Standards, Implementation Specifications, and Certification Criteria for Electronic
Health Record Technology” (Federal Register 2012) 13840.
TBD 10
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 updates his/her records, makes any changes to the Plan of Care, signs his/her approval, and sends it
2 back to the Home Health provider.
3 Throughout the Home Health episode, which may range from several days to many months, the Home
4 Health provider contacts the physician to reconcile changes in the patient’s condition and Plan of Care
5 as the patient’s condition and needs change, sending each change to the physician for review and
6 approval. The physician can also initiate changes to the Plan of Care as his/her assessment of the
7 patient’s conditions and needs develop over time.
8 Home Health agencies cannot provide services until authorized by the physician, and cannot bill
9 Medicare or Medicaid for services until the physician has approved them in the Plan of Care. Home
10 Health providers therefore spend a good deal of effort following up with physicians to have them sign
11 the initial Plan of Care and subsequent changes.
12 In almost all cases today, HH-POC travels between the Home Health provider and the physician as a
13 paper or faxed form. This is true even though the Home Health provider may generate the Plan of Care
14 from data it holds in electronic form in its EMR, and even though the physician may use an EMR for all of
15 his/her patient records4.
16 Please see the Home Health Plan of Care “Developing Interoperability Standards for Home Health Plan
17 of Care: Use Case” document developed by the Visiting Nursing Services of New York (VNSNY) in
18 collaboration with relevant stakeholders for a detailed view of the operational aspects of exchanging the
19 HH-POC. The Baseline Use Case will focus only on the requirements needed for the HH-POC
20 transactions.
21 2.4 Policy Issues
22 The LCC WG will produce a separate white paper that will provide a data interoperability-focused
23 supplement to the existing policy work produce by AHIMA/ ASPE.5 It is important, however, to briefly
24 identify the relevant policy drivers. To that end, the Affordable Care Act (ACA) mandates multiple pilots
25 involving coordination of care, particularly at transfers in care and for instances of shared care. The LCC
26 WG seeks to inform the discussions of both the Health Information Technology Policy Committee
27 (HITPC) and the Health Information Technology Standards Committee (HITSC) by defining
28 interoperability standards applicable to LTPAC providers as well as laying out a long-term roadmap for a
29 longitudinal care record that includes a longitudinal care plan.
30 A policy driver for the HIT Policy Committee is to recognize the need to support and advance
31 interoperable electronic exchange and use of health information on behalf of persons who receive
32 LTPAC services. While LTPAC providers are not included in the Medicare and Medicaid Meaningful Use
33 Programs, as described in this use case, patients served by LTPAC are concurrently served by and
34 transition across health care settings by those Eligible Professionals and Eligible Hospitals that qualify for
35 incentives under the Meaningful Use program. The Meaningful Use Stage 2 NPRM improves the
36 standing of LTPAC with several references to LTPAC settings as well as longitudinal care planning, but
4
“Developing Interoperability Standards for Homecare Plan of Care Exchange: Use Case,” (Visiting Nursing Services
of New York 2011) 10.
5
Michelle Dougherty and Jennie Harvell, “Opportunities for Engaging Long-Term and Post-Acute Care Providers in
Health Information Exchange Activities,” (American Health Information Management Activities 2011) 1-39.
TBD 11
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 there must be additional specificity in both the MU 2 NPRM and in the EHR Certification Criteria to
2 specifically identify the role and inclusion of LTPAC sites in the fulfillment of MU requirements.
3 The LCC WG is also positioned to inform the work of the HITSC by developing detailed interoperability
4 specifications that are appropriate for LTPAC settings. This will be accomplished in the first by extending
5 the Transitions of Care work accomplished to date. Second, the LCC WG and this Use Case will define
6 some foundational Plan of Care transactions to set a practical starting place for the broader LCC work to
7 further define interoperability for shared care to follow.
8 The User Story and Activity Diagrams represent a generalized flow of information exchange, but do not
9 represent infrastructure, architecture, or workflow requirements. They show what information needs to
10 go from place A to place B to achieve a clinically sound transfer of care and enable shared care for the
11 patient; however, they do not dictate the content or format of this information nor the specific
12 transactions for the transfer of this information. It is left to policy makers to determine what
13 requirements are applied to providers.
14 2.5 Regulatory Issues
15 Implementation of the LCC Use Case supports the following regulatory requirements from Meaningful
16 Use Stage 1 as well as the requirements proposed in Meaningful Use Stage 2:
17
18 The Final Rule for Health Information Technology: Initial Set of Standards, Implementation
19 Specifications, and Certification Criteria for Electronic Health Record Technology for Meaningful Use
20 Stage 1 state the following:
21 A. Initial Set of Standards, Implementation Specifications, and Certification for Electronic Health
22 Record Technology (July 2010) identified the following standard for Engagement of Patients and
23 Families in their Healthcare:
24
25 (1) Electronic Copy of Health Information: Electronic copy of health information. Enable a user to
26 create an electronic copy of a patient’s clinical information, including, at a minimum: diagnostic test
27 results, problem list, medication list, and medication allergy list in: (1) Human readable format; and
28 (2) On electronic media or through some other electronic means in accordance with: (i) The standard
29 (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii)
30 For the following data elements the applicable standard must be used:
31 (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard
32 specified in §170.207(a)(2);
33 (B) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and
34 (C) Medications. The standard specified in §170.207(d) Electronic Copy of *Discharge Instructions:
35 Electronic copy of discharge instructions enable a user to create an electronic copy of the discharge
36 instructions for a patient, in human readable format, at the time of discharge on electronic media or
37 through some other electronic means.
38
39 (2) *Electronic Copy of Discharge Instructions: Electronic copy of discharge instructions. Enable a
40 user to create an electronic copy of the discharge instructions for a patient, in human readable
41 format, at the time of discharge on electronic media or through some other electronic means.
42
43 (3) Clinical Summaries for each Office Visit: Clinical summaries enable a user to provide clinical
44 summaries to patients for each office visit that include, at a minimum: diagnostic test results,
TBD 12
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 problem list, medication list, and medication allergy list. If the clinical summary is provided
2 electronically it must be: (1) Provided in human readable format; and (2) Provided on electronic
3 media or through some other electronic means in accordance with: (i) The standard (and applicable
4 implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the
5 following data elements the applicable standard must be used:
6 (1) Problems. The standard specified in §170.207(a) (1) or, at a minimum, the version of the
7 standard specified in §170.207(a) (2);
8 (2) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and
9 (3) Medications. The standard specified in §170.207(d).
10
11 B. Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic
12 Health Record Technology (July, 2010) identified the following standard for Improvement in Care
13 Coordination:
14
15 (1) Enable a user to create an electronic copy of a patient’s clinical information, including, at a
16 minimum, diagnostic test results, problem list, medication list, medication allergy list, and
17 procedures: (I) In human readable format, and (ii) on electronic media or through some other
18 electronic means in accordance with: (A) The standard (and applicable implementation
19 specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (B) For the following data elements
20 the applicable standard must be used:
21
22 (1) Problems. The standard specified in §170.207(a) (1) or, at a minimum, the version of the
23 standard specified in §170.207(a) (2);
24 (2) Procedures. The standard specified in §170.207(b) (1) or §170.207(b) (2);
25 (3) Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and
26 (4) Medications. The standard specified in §170.207(d).
27
28 (2) Enable a user to create an electronic copy of a patient’s discharge summary in human readable
29 format and on electronic media or through some other electronic means
30 The Meaningful Use Stage 2 Proposed Rule sets out the likely elements of the final rule and asks for
31 specific public comment. Note the following sections from the Health Information Technology:
32 Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record
33 Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information
34 Technology:
35 Consistent with our discussion in the preamble section titled “Explanation and Revision of Terms
36 Used in Certification Criteria,” we have replaced the terms “modify” and “retrieve” in the
37 recommended criterion with “change” and “access,” respectively. Further, consistent with the
38 interpretation we provided in the S&CC July 2010 final rule, we are reiterating and clarifying that
39 “longitudinal care” is used to mean over an extended period of time. For the ambulatory setting,
40 this would be over multiple office visits. For the inpatient setting, this would be for the duration
41 of an entire hospitalization, which would include the patient moving to different wards or units
42 (e.g., emergency department, intensive care, and cardiology) within the hospital during the
43 hospitalization. The HITSC suggested that we consider longitudinal care to cover multiple
44 hospitalizations, but we believe this could be difficult to achieve and may not offer added value
45 based on the duration of time between a patient’s hospitalizations and the reason for the
46 hospitalizations. To note, our clarification of the meaning of longitudinal care applies equally to
TBD 13
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 its use in other certification criteria, such as “medication list” and “medication allergy list.” If we
2 were to change our interpretation of longitudinal care as suggested by the HITSC, it would apply
3 to these certification criteria as well and could constitute a change in the capabilities included in
4 the criteria, which in turn would cause them to become revised certification criteria. We
5 welcome comments on our interpretation of longitudinal care. We also welcome comments on
6 whether a term other than “longitudinal care” could and should be used to express the capability
7 required by this certification criterion and the other referenced certification criteria (“medication
8 list” and “medication allergy list”). We understand that the longitudinal care description we use
9 for the purposes of EHR technology certification may differ from the meaning that providers
10 attribute to it, including the meaning given to it by the Longitudinal Coordination of Care
11 Workgroup within the Standards and Interoperability Framework.6
12
13 As we continue to adopt new and revised certification criteria to support MU, we believe that it is
14 prudent to seek public comment on whether we should focus our efforts on the certification of
15 the HIT used by health care providers that are ineligible to receive incentives under the EHR
16 Incentive Programs. In particular, we are interested in commenters’ thoughts on whether we
17 should consider adopting certification criteria for other health care settings, such as the long-
18 term care, post-acute care, and mental and behavioral health settings. For those commenters
19 that believe we should consider certification criteria for other health care settings, we
20 respectfully request that their comments specify the certification criteria that would be
21 appropriate as well as the benefits they believe a regulatory approach would provide. Last, we
22 ask that the public consider whether the private sector could alternatively address any perceived
23 need or demand for such certification. For example, we are aware that the Certification
24 Commission for Health Information Technology (CCHIT) has certification programs for long-term
25 and post-acute care as well as behavioral health EHR technology.7
26
27 We are interested in whether commenters believe that EHR technology certified to the 2014
28 Edition EHR certification criteria should be capable of recording the functional, behavioral,
29 cognitive, and/or disability status of patients (collectively referred to as “disability status”). The
30 recording of disability status could have many benefits. It could facilitate provider identification
31 of patients with disabilities and the subsequent provision of appropriate auxiliary aids and
32 services for those patients by providers. It could also promote and facilitate the exchange of this
33 type of patient information between providers of care, which could lead to better quality of care
34 for those with disabilities. Further, the recording of disability status could help monitor
35 disparities between the “disabled” and “nondisabled” population.
36
37 We are specifically requesting comment on whether there exists a standard(s) that would be
38 appropriate for recording disability status in EHR technology. We are aware of a standard for
39 disability status approved by the Secretary for use in population health surveys sponsored by
40 HHS46 and standards under development as part of the Standards and Interoperability
41 Framework and the Continuity Assessment Record and Evaluation (CARE) assessment tool8. We
6
“Health Information Technology: Standards, implementation Specifications, and Certification Criteria for
Electronic Health Record Technology, 2014 Edition.” Federal Register 77 (7 March 2012): 13832.
7
“Health Information Technology: Standards, implementation Specifications, and Certification Criteria for
Electronic Health Record Technology, 2014 Edition.” Federal Register 77 (7 March 2012): 13871.
8
“Health Information Technology: Standards, implementation Specifications, and Certification Criteria for
Electronic Health Record Technology, 2014 Edition.” Federal Register 77 (7 March 2012): 13872.
TBD 14
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 welcome comments on whether these standards or any other standards would be appropriate
2 for recording disability status in EHR technology.
3
4 We ask that commenters consider whether the recording of disability status should be a required
5 or optional capability that EHR technology would include for certification to the 2014 Edition EHR
6 certification criteria. We also ask commenters to consider whether the recording of disability
7 status should be part of a Base EHR and included in a separate certification criterion or possibly
8 the “demographics” certification criterion (§ 170.314(a)(3)). Last, we ask commenters to consider
9 whether disability status recorded according to the standard should also be included in other
10 certification criteria such as “transitions of care – incorporate summary care record”
11 (§170.314(b)(1)), “transitions of care – create and transmit summary care record”
12 (§170.314(b)(2)), “view, download and transmit to 3rd party” (§ 170.314(e)(1)), and “clinical
13 summaries” (§ 170.314(e)(2)).9
14
15 (5) Problem list. Enable a user to electronically record, change, and access a patient’s problem list
16 for longitudinal care in accordance with, at a minimum, the version of the standard specified in §
17 170.207(a)(3).
18
19 (6) Medication list. Enable a user to electronically record, change, and access a patient’s active
20 medication list as well as medication history for longitudinal care.
21
22 (7) Medication allergy list. Enable a user to electronically record, change, and access a patient’s
23 active medication allergy list as well as medication allergy history for longitudinal care.10
24
25 2.6 Communities of Interest
26 Communities of Interest are public and private stakeholders that are directly involved in the business
27 process or are involved in the development and use of interoperable implementation guides and in their
28 actual implementation. Communities of Interest may directly participate in the exchange; that is, they
29 are business actors; or indirectly through the results of the improved business process.
30 The following list of Communities of Interest and their definitions are for discussion purposes for Clinical
31 Information Exchange.
Member 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 and
LTPAC sites of care.
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
9
“Health Information Technology: Standards, implementation Specifications, and Certification Criteria for
Electronic Health Record Technology, 2014 Edition.” Federal Register 77 (7 March 2012): 13872.
10
“Health Information Technology: Standards, implementation Specifications, and Certification Criteria for
Electronic Health Record Technology, 2014 Edition.” Federal Register 77 (7 March 2012): 13881.
TBD 15
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Member of Communities of Interest Working Definition
receiving healthcare services.
Care Coordinators Individuals who support clinicians, patients, and/or
other consumers in the management of health and
disease conditions, physical and cognitive functioning,
and issues related to health and human services . These
can include case managers and others.
Caregiver
Clinicians Healthcare providers with patient care responsibilities,
including physicians, advanced practice nurses,
physician assistants, nurses, psychologists, pharmacists,
social workers, therapists, and other licensed and
credentialed personnel involved in treating patients.
Includes an individual clinician in a care delivery setting
who requests, submits or accepts the transfer of the
clinical summary for the purposes of delivering care.
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 Includes a wide array of individual providers and
provider organizations that are engaged in or support
the delivery of health and human services. Includes but
is not limited to Hospitals (including short-term acute
care hospitals and specialty hospitals (e.g., long-term
care hospitals, rehabilitation facilities, and psychiatric
hospitals)), Ambulatory Centers, Provider Practices,
Nursing Facilities, Home and Community-Based Service
Providers (e.g., Home Health Agencies, Hospice, Adult
Day Care Centers, etc. ), and human and social service
providers (e.g., transportation).
Provider Organizations Organizations that: are either vertically and/or
horizontally integrated configurations of providers,
typically sharing a common governance body, and are
engaged in or support the payment, delivery, and/or
management of healthcare and/or long-term care
services. Examples of such organizations include: IDNs,
ACOs, PCMH, etc…
Provider Systems
Service Providers
Standards Organizations Organizations whose purpose is to define, harmonize
TBD 16
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Member of Communities of Interest Working Definition
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 care,
long-term care, and/or human services.
Electronic Health Record/Personal Health Vendors which provide clinicians and consumers
Record and HISP (Health Information specific EHR/PHR solutions such as software
Service Provider) Vendors applications and software services.
HISP organizations provide the technical capability to
transmit the ToC messages across diverse EHR/PHR
systems. These suppliers may include developers,
providers, resellers, operators, HIEs and others who
may provide these or similar capabilities.
1 Table 1: Communities of Interest
2 3.0 Challenge Statement
3 Meaningful Use Stage 1 and proposed Stage 2 criteria require information to be exchanged in transitions
4 of care. Additionally, this Use Case recognizes that a significant number of shared care interactions
5 occur, in the form of the plan of care, between disparate providers when a patient remains in the same
6 care setting. Implementers are often confused about how to adopt the specifications for exchange of
7 the required data for both transition and non-transition shared care. The content of any exchange is
8 only as good as its fidelity to source, assured identity, provenance, completeness, audit/traceability, full
9 context, along with permissions and qualifications. Without ensuring these characteristics across
10 information exchanges such that all are fully evident to the receiver (and ultimate user), no exchange is
11 valid. Furthermore, this exchange is dependent on a secure, interoperable environment.
12 Different transition and non-transition scenarios may require different types of artifacts (e.g. a transition
13 from inpatient to ambulatory may require a discharge summary; a transition from primary care provider
14 to a consultant may require a referral summary, a stationary patient requires a plan of care, etc…). All of
15 these artifacts should draw from a common framework. As part of that framework, we should allow for
16 different data elements to be communicated as needed. In all cases, the ToC or HH-POC transaction
17 should support existing clinical workflows, and data overloading the recipient clinician must be avoided.
18 Ultimately, the data needs of the patient and caregivers should be considered because it is the
19 providers, patient (and/or their legal representative) that are the recipient end users of the data.
20 The challenge of data overload cuts both ways. It is inefficient for “senders” to collect information that
21 provides no clinical benefit to the patient or guidance to the receiving clinician. It is also inefficient for
22 “receivers” to wade through extraneous information to find the relevant data elements. This challenge
23 can be met with two “filtering” processes, one for the sender and one for the receiver.
24 Among the deliverables of this initiative are datasets specific to sending and receiving sites that are
25 purpose and patient specific and which contain only those data elements required by the receiving
26 clinicians. No data elements other than these will be required. In this way, “senders” are protected from
27 gathering and sending more information than is needed.
TBD 17
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 The Consolidated CDA emerged from work undertaken by the ToC Initiative as described in the ToC V1.1
2 Use Case. Among other improvements, important data elements were added to the CCD document and
3 a Discharge Summary document was defined. Improvements are currently underway to enhance the C-
4 CDA to enable the interoperable exchange of Functional, Cognitive and Pressure Ulcer information that
5 is critical for the safe and efficient transfer and care of LTPAC patients. This Use Case will not assume the
6 use of the C-CDA, but will provide the necessary functional and data set guidance in order to improve
7 the capabilities of the C-CDA should that standard be adopted in the Standards Harmonization phase of
8 implementing this Use Case.
9 The challenges for transitions of care in this Use Case are:
10 Update and refine the ToC V1.1 “Core” data set that would be required in all ToC circumstances;
11 Identify the kinds of data beyond this “Core” data set needed to define generic LTPAC transfers
12 of care based initially on the HHA and Nursing Facility care settings;
13 To define a uniform way of structuring commonly used information;
14 To provide a robust tool-set to aid in the development and validation of conforming
15 implementations to support widespread adoption with a specific focus on LTPAC settings.
16 Providing guidance to implementers on how to utilize the data defined in patient assessments
17 (MDS 3.0 and OASIS C) to construct the transitions of care data sets.
18 The challenges for shared care as embodied in the plan of care in this Use Case are:
19 Defining the data sets and detailed data elements required to construct an interoperable plan
20 of care for the initial, interim and recertification uses of the Home Health POC;
21 The electronic signing of the Home Health POC by the physician to authorize the orders
22 provided in the HH-POC;
23 Aligning ToC and HH-POC data elements where possible and practical to ensure consistency and
24 reusability in implementation;
25 Providing guidance to implementers on how to utilize the data defined in patient assessments
26 (MDS 3.0 and OASIS C) to construct the plan of care data sets.
27 4.0 Value Statement
28 The standardized patient clinical summary will provide timely, accurate, and structured information at
29 the point of care to the receiving provider as well as offering enhanced clinical information to the
30 patient. The accuracy and appropriate amount (the data required for the care of the patient without
31 data overload) of clinical information will ensure that clinicians provide high quality care and patients
32 will now become more involved and be informed of their care overall leading to a patient centric
33 approach and patient empowerment. Enhancing a patient’s ability to make well informed decisions
34 about their healthcare can be supported by the patient having access to their health information.
35 The standardized Home Health plan of care will provide timely, accurate and structured information for
36 actors involved in the creation and maintenance of the plan of care as well as informing patients and/ or
37 the patient’s care delegate.
38 Defining the minimum data elements to be exchanged and mapping them to MU specified formats will
39 facilitate standardized functionality becoming rapidly incorporated into certified EHR vendor offerings
40 and better enable providers to use the specifications in a timely manner to exchange the required
41 clinical data between care settings and with their patients.
TBD 18
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 For Home Health providers and physicians who use EMRs, there are two major benefits from an
2 electronic exchange of the Home Health Plan of Care: reducing overhead effort through greater
3 efficiency, and improving clinical outcomes through fuller collaboration.
4 Efficiency: An electronic exchange of the Plan of Care between the EMRs of the Home Health
5 provider and the physician can improve efficiency for both parties. It places the Plan of Care in
6 the physician’s electronic inbox to review and act on as part of their daily workflow. It eliminates
7 the large amount of time wasted in phone tag and the frustration of the Home Health provider
8 in not obtaining a timely signed order. It reduces paper and fax, and corresponding manual
9 processes. It also eliminates the need for physicians to use the disparate physician portals that
10 are currently hosted by many individual HHAs, and are outside of the physicians’ EMRs and their
11 typical daily workflow, to approve Plans of Care. The electronic exchange is integrated with the
12 EMRs that both parties are already using to automate their patient care activities; it fits their
13 preferred workflow in the most efficient way. Physicians may also find that it provides
14 documentation of their oversight of Home Health patients, which is a billable activity for which
15 physicians can obtain reimbursement.
16 Collaboration: The electronic exchange of the Plan of Care may also promote collaboration by
17 supporting the timely transmission of relevant clinical information at the start of Home Health
18 and as the patient’s condition changes. It enables both the physician and the Home Health
19 provider to initiate changes to the Home Health treatment more promptly as the patient’s
20 needs change. Because both parties are working within their EMR in this exchange, the
21 communication occurs immediately in the clinical process. For patient-centered medical homes
22 (PCMH), not only are the physician and the Home Health provider the beneficiaries of this
23 improved collaboration but the whole PCMH team as well. This exchange will also promote
24 collaboration in future care delivery models such as Accountable Care Organizations (ACO)
25 where care coordination and care management are essential.
26 Furthermore, building on the use of electronic health records by exchanging data electronically to
27 increase workflow efficiencies and clinician collaboration, thereby improving patient outcomes, will
28 contribute to an overall decrease in healthcare costs in the years to come. Cost savings may come from
29 avoided medical errors, decreased likelihood of harmful drug-to-drug interactions, and improved
30 transitions of care, as records would contain information from all patient encounters within the medical
31 system.11
32 5.0 Use Case Assumptions
33 Assumptions for this Use Case are the following:
34 Transitions of Care to and from LTPAC are setting to setting transfers, each involving the
35 contributions of one or more providers to complete the required dataset. This requires another
36 level of organization that provides not only to capability of transferring and receiving clinical
37 summaries, but also the capability to construct them from inputs from the required participants.
11 Randall Brown, “Strategies for Reigning in Medicare Spending Through Delivery System Reforms: Assessing the
Evidence and Opportunities,” Paper prepared for The Henry J. Kaiser Family Foundation, September 2009. p. 4.
TBD 19
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 Data collected electronically for reporting and assessment or other uses are available for re-use
2 for the transactions in this use case.
3 When possible and appropriate, the information from the transactions in this use case will be
4 used to populate or inform the relevant patient assessment instruments at the receiving site.
5 A provider is an individual clinician in a care delivery setting who submits or receives the
6 transfer of the clinical message for the purposes of delivering care.
7 The transferring or referring provider or Provider Organization has an EHR system or other
8 computer system capable of producing the required structured document(s).
9 The receiving facility, if LTPAC, has the capability of receiving and incorporating the structured
10 transmission of data into their local EHR system.
11 The EHR, other computer system or PHR system is capable of ensuring that content of the
12 transactions in this use case (as exchanged) maintain its fidelity to source, as well as assured
13 identity, provenance, completeness, audit/traceability, full context, along with permissions and
14 qualifications necessary for transmittal/disclosure (source/sending EHRs/PHRs/ other relevant
15 clinical system) and for receipt (receiving EHRs/PHRs/ other relevant clinical systems).
16 The transmission of data may occur directly between network partners or via HISPs or Health
17 Information Exchanges as data may be transmitted to multiple EHRs, HIEs, repositories and
18 providers
19 a. Some exchanges may require HISP to HISP connectivity
20 The providers participating in direct information exchanges and in HISP mediated exchange
21 services have established network and policy infrastructure to enable consistent, appropriate,
22 and accurate information exchange across clinical systems, EHRs, PHRs, data repositories (if
23 applicable) and locator services. This includes, but is not limited to:
24 Methods to identify and authenticate users
25 Methods to identify and determine providers of care
26 Methods to enforce data access authorization policies
27 Security and privacy policies, procedures and practices are commonly implemented to support
28 acceptable levels of patient privacy and security; i.e. HIPAA, HITECH and EHR certification
29 criteria
30 The Patient has and uses a PHR or has access to portal.
31 At least two separate EHR systems maintaining a “synchronized” plan of care – Home Health
32 Agency and PCP/Medical Home ;
33 • Synchronization interval and/or events are defined - Rules for emergent, routine, periodic;
34 • After initiation of the plan of care and replication in separate EHR systems, incremental updates,
35 based on interim changes to HH-POC, are sent;
36
37 Appendix C provides more details on Privacy and Security assumptions.
38 6.0 Pre-Conditions
39 Pre-conditions are those conditions that must exist for the implementation of the ToC and HH-POC
40 interoperability Information Exchanges.
41 PHR, EHR or other relevant clinical systems are in place.
42 The Patient is registered in all systems.
TBD 20
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 The Provider has treated the Patient or has been requested to treat the patient by another
2 provider.
3 Relevant clinical information that will be exchanged is available in the sending system.
4 There are methods to ensure the veracity of data.
5 Clinicians securely access clinical information through an EHR system or other clinical system.
6 Patients may securely access clinical information through a PHR system.
7 Appropriate standards protocols; patient identification methodology; consent; privacy and
8 security procedures; coding, vocabulary and normalization standards have been agreed to by all
9 relevant participants.
10 Legal and governance issues regarding data access authorizations, data governance, and data
11 use are in effect.
12 7.0 Post Conditions
13 Post Conditions are those conditions that exist after the Clinical Information Exchange.
14 Clinical Information is successfully reported and electronically transmitted between Sending
15 Provider to Receiving Provider or Patient PHR and (1) is accessible by the Receiving
16 Provider/Patient through an EHR/PHR system and (2) is displayed in a human readable format.
17 Clinical Information is accessible by the Electronic Health Record application or other relevant
18 clinical system.
19 Clinical Information is accessible by the Personal Health Record application.
20 8.0 Actors and Roles
21 This section describes the Business Actors that are participants in the information exchange
22 requirements for each scenario. A Business Actor is an abstraction that is instantiated as an IT system
23 application that a Stakeholder uses in the exchange of data needed to complete Use Case action(s); a
24 Business Actor may be a Stakeholder. Furthermore, the systems perform specific roles in this Use Case
25 as listed below:
Business Actor – Business Actor – System Role
Generic Specific
Acute care Hospital Inpatient Hospital EHR Provides Transfer of Care
providers System Summary (Discharge
summary and discharge
instructions)
Receives Transfer of Care
Summary
Provides copies to PHR
Hospital ED ED EHR System Receives Consultation
Request Clinical Summary
Provides Shared Care
Encounter Summary
Provides copies to PHR
Ambulatory Care Primary Care Provider EHR Receives Transfer of Care
Providers Physician/Patient System Summary
TBD 21
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Business Actor – Business Actor – System Role
Generic Specific
Centered Medical Home Sends Consultation Request
(PCP/PCMH) Clinical Summary
Receives Shared Care
Encounter Summary
Receives Initial & Recertified
Home Health Plan of Care
Sends Initial & Recertification
HH-POC
Receives interim changes to
HH-POC
Sends interim changes to HH-
POC
Provides copies to PHR
Hospital Hospital/Other Receives Consultation
Outpatient/Other EHR System Request Clinical Summary Comment [kc1]: Note: Look at consultant
Ambulatory Service Sends Shared Care Encounter definition
Provider Summary
Provides copies to PHR
LTPAC Nursing Facility (NF) NF Information Sends Consultation Request
System Clinical Summary
Receives Shared Encounter
Summary
Provides copies to PHR
Home Health Agency HHA Information Receives the Transfer of Care
(HHA) System Summary
Provides Initial &
Recertification Plan of Care
Receives Initial &
Recertification POC
Sends and receives Ongoing
POC
Sends copies to PHR
1 Table 2: Actors and Roles of Use Case
2
TBD 22
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 9.0 Use Case Diagram
2 The following diagram depicts the exchange to support the Elements in Transition of Care Use Case.
3 1. The ability of the Electronic Health Record System to send and/or receive Clinical Information
4 through a HISP.
5 2. The ability of the Personal Health Record to send and/or receive Clinical Information through a
6 HISP.
7
8 Transitions of Care and Plan of Care Use Case Diagram
9
10 Figure 1: Use Case Diagram
11
TBD 23
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 Transitions of Care and Plan of Care Context Diagram
ion HH
tat
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3 Figure 2: Context Diagram
TBD 24
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 10.0 Scenario 1: The Exchange of Clinical Summaries from Provider to
2 Provider
3 Introduction to Scenarios:
4 As described in the Scope section, the Use Case has four scenarios: the first focuses on the perspective
5 of provider to provider exchange of clinical summaries upon transferring a patient and for a consultation
6 referral. Scenario 2 focuses on the Initial, Recertification and Interim Home Health Plan of Care. Scenario
7 3 focuses on the perspective of the providers sending the clinical summaries and plan of care to patients
8 and their PHR. Scenarios 1 and 2 are a provider perspective while scenario 3 takes the patient
9 perspective of being informed by the copies received of the provider transactions. In an actual instance
10 of care, both provider to provider and provider to patient transactions would take place.
11 Assumptions:
12 1. Pre-transfer negotiations between providers are out of scope.
13 2. At a minimum, informal agreement to treat is needed from both the patient and the other
14 provider for actual transfer or referral of patient to take place. Similarly informal agreement to
15 receive the clinical information by the other provider and by the patient is necessary for
16 information exchange to take place, as is traditional in current actual medical practice.
17 3. The Transfer of Care Summary will be available at or before the time that the patient is
18 transferred.
19 10.1 User Stories of Scenario 1
20 The User Stories illustrate a combination of events in the scenario flows which are described in further
21 detail in the tables that follow. The User Stories rely on the definition of broad datasets that were
22 outlined by the LCC WG. The datasets for Transitions of Care are nested as follows: Comment [kc2]: Terry to provide language
around types of transfers.
23 1. Test/ Procedure Report: Report from Outpatient testing, treatment, or procedure
24 2. Test/ Procedure Request: Referral to Outpatient testing, treatment, or procedure
25 3. Shared Care Encounter Summary: Office Visit, Consultation Summary, Return from the ED to the
26 referring facility
27 4. Consultation Request Clinical Summary: Referral to a consultant or the ED
28 5. Transfer of Care Summary: Permanent or long-term transfer to a different provider, care team
29 or Home Health Agency
30
31 Of these 5 datasets Scenario 1 focuses on types 3, 4 and 5. Type one and two are considered to be
32 included as a subset in types three, four and five. The datasets are considered to be overlapping making
33 dataset one a subset of dataset 2 and so on. The following diagram illustrates the overlapping nature of
34 the transitions of care datasets that are further described in this scenario.
TBD 25
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Type 3 Dataset:
• Office Visit to PHR
• Consultant to PCP
• ED to PCP, SNF, etc…
1 – Test/Procedure Report
2 – Test/Procedure Request
3 – Shared Care Encounter Summary
4 – Consultation Request Clinical Summary
Type 4 Dataset:
5 – Transfer of Care Summary Type 5 Dataset:
• PCP to Consultant • Hospital to SNF, PCP, HHA, etc…
• PCP, SNF, etc… to ED • Hospital, SNF, etc… to HHA
1
• PCP to new PCP
2 This diagram notes that there is more than one scenario for which the same dataset can be used. It is
3 the intent of this Baseline Use Case is to focus on following specific transactions:
4 Scenario 1: Provider to Provider data exchanges for Transfers of Care and Referral that support
5 the following generic and [representative] interactions:
6 a. Acute Care Hospital to LTPAC site (Transfer of Care Summary);
7 b. LTPAC Site to Emergency Department/ Consultant (Consultation Request Clinical
8 Summary);
9 c. Emergency Department/ Consultant to LTPAC Site (Shared Care Encounter Summary).
10 However, it is intended that similar trading partners (e.g. Nursing Facilities or Inpatient Rehabilitation
11 Facilities receiving a patient from Acute Care) may also take advantage of the transactions that are
12 articulated in this Use Case and that future use cases will specifically consider the inclusion of new data
13 elements based on the needs of other specific trading partners (e.g. behavioral health, community-
Comment [kc3]: Ensure concept of exemplar is
14 based organizations). strongly conveyed. Datasets are not setting specific,
but transition specific. Temporary/ Permanent,
elective or emergent. Assigned to Terry O.
TBD 26
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 User Story 1: The Exchange of Information to Support the Transfer of Patient Information from One
2 Provider to Another
3 During preparation for discharge from acute care hospital inpatient status, it is determined that the
4 patient will need home health care. Following consultation with the patient and family, the attending
5 physician writes the order for home health care. The hospital arranges with a local home health agency
6 (HHA) to begin such care upon discharge. The hospital prepares a transfer of care summary (dataset 5)
7 and sends it to the HHA with a copy to the patient’s primary care physician12. The patient is discharged
8 with patient instructions and is transported home.
9 The HHA reviews the transfer of care summary (dataset 5) and incorporates it into its information
10 system. It sends a home health clinician to assess the patient and initiate the Home Health Plan of Care
11 (HH-POC).
12 User Story 2: The Exchange of Consultation Request Clinical Summary and Shared Care Encounter
13 Summary for the Referral of Patient from a Nursing Facility to ED and Return from ED to Nursing
14 Facility
15 Setting 1: Nursing Facility (sends consultation request clinical summary to Emergency Department/
16 Consultant).
17 A patient is receiving care in a nursing facility (NF). Over a weekend evening, the patient experiences
18 sudden and unexpected respiratory changes. The nurse on duty checks with the attending physician
19 who instructs the NF to send the patient to the local hospital’s emergency department (ED) for
20 evaluation. The NF team member transmits a consultation request clinical summary (dataset 4) for the
21 patient to the ED. The ED incorporates the summary into its system to make it available for the ED staff.
22 The patient is transported to the ED where the patient is evaluated, treated and held for observation.
23 The patient is successfully stabilized.
24 Setting 2: Emergency Department (sends Shared Care Encounter Summary to Nursing Facility and
25 PCP/ PCMH).
26 The ED arranges transport back to the NF. The ED sends a shared care encounter summary (dataset 3)
27 documenting care to the NF and the patient’s NF PCP/PCMH. The NF and PCP/PCMH resume care of the
28 patient and incorporate the summary into their information systems.
29 10.1.1 Base Flow of Scenario 1
30 User Story 1: The Exchange of Transfer of Care Summary for the Discharge of a Patient from Hospital
31 to Home Health Agency.
Step # Actor Event/Description Inputs Outputs
1 Provider Creates Discharge Order and START Orders for Discharge
Order for Home Health Care and Home Health Care
(HHA)
12
Note that the PCP/PCMH receives the same Transfer of Care Summary as the HHA. To the extent that the
Transfer of Care Document is different from a Discharge Summary in timing or content, this transaction is similar to
Scenario 1 User Story 1 in the original Transfer of Care Use Case.
TBD 27
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
2 Hospital Inpatient Prepares and sends Transfer of Discharge Order Transfer of Care
EHR System Care Summary to HHA and Summary and
PCP/PCMH Discharge Instructions
3A HHA Information Receives Transfer of Care Transfer of Care END
System Summary and Initiates Summary
Assessment
3B PCP/PCMH EHR Receives Transfer of Care Transfer of Care END
System Summary Summary
1 Table 3: Base Flow of Scenario 1 User Story 1
2
3 User Story 2: The Exchange of Consultation Request Clinical Summary and Shared Care Encounter
4 Summary for the Referral of Patient from a Nursing Facility to ED and Return from ED to Nursing
5 Facility
Step # Actor Event/Description Inputs Outputs
1 NF Information Intent to treat urgent symptoms START Order for ED
System in ED Referral
2 NF Information Prepares and sends Consultation Order for ED Consultation
System Request Clinical Summary to ED Referral Request
Clinical
Summary
3 ED EHR System Receives Consultation Request Consultation Shared Care
Clinical Summary; evaluates Request Clinical Encounter
patient, provides care and sends Summary Summary
patient and Shared Care
Encounter Summary back to NF
and PCP/ PCMH
4A NF Information Receives Shared Care Encounter Shared Care END
System Summary Encounter Summary
4B PCP/PCMH EHR Receives Shared Care Encounter Shared Care END
System Summary Encounter Summary
6 Table 4: Base flow of Scenario 1 User Story 2
7
TBD 28
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 10.1.2 Activity Diagrams for Scenario 1
2 The following are the Activity Diagrams to support the events in section 10.1.1.
3 User Story 1: The Exchange of Transfer of Care Summary for the Discharge of a Patient from Hospital
4 to Home Health Agency
Provider Hospital Inpatient EHR HHA Information System PCP/PCMH EHR System
System
1. Creates discharge 2. Prepares and sends
3A. Receives Transfer 3B. Receives Transfer
order and order for Transfer of Care
of Care Summary and of Care Summary and
home health care Summary to HHA and
initiates assessment initiates assessment
(HHA) PCP/PCMH
5
6 Figure 3: Activity Diagram of Scenario 1 User Story 1
7 User Story 2: The Exchange of Consultation Request and Shared Care Summary for the Referral of
8 Patient from a Nursing Facility to ED and Return to Nursing Facility
PCP/PCMH EHR System NF Information System ED EHR Information System
1. Intent to treat urgent
symptoms in ED
3. Receives Consultation
Request Clinical
2. Prepares and sends Summary, evaluates and
Consultation Request provides care, sends
Clinical Summary to ED patient and Shared Care
Encounter Summary back
to NF and PCP/PCMH
4A. Receives Shared 4B. Receives Shared
Care Encounter Summary Care Encounter Summary
9 Figure 4: Activity Diagram of Scenario 1 User Story 2
TBD 29
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 10.2 Functional Requirements of Scenario 1
2 10.2.1.1 Information Exchange Requirements of Scenario 1 User Story 1
3
Dataset Initiating Action Information Action Receiving
Transaction Type System Interchange System
Requirement Name
1 Type 5 Hospital Sends Transfer of Care Receives HHA
Inpatient EHR Summary (discharge Information
System summary and System
instructions)
1A Type 5 Hospital Sends Transfer of Care Receives PCP/ PCMH
Inpatient EHR Summary (discharge EHR System
System summary and
instructions)
4 Table 5: Information Exchange Requirements of Scenario 1
5
6 10.2.1.2 Information Exchange Requirements of Scenario 1 User Story 2
7
Dataset Initiating Action Information Action Receiving
Transaction Type System Interchange System
Requirement Name
2 Type 4 NF Sends Consultation Request Receives ED EHR System
Information Clinical Summary
System
3A Type 3 ED EHR Sends Shared Care Receives NF
System Encounter Summary Information
System
3B Type 3 ED HER Sends Shared Care Receives PCP/PCMH
System Encounter Summary EHR System
8 Table 6: Information Exchange Requirements of Scenario 1 User Story 2
9
10 10.2.2 System Requirements of Scenario 1 User Stories 1 and 2
System Requirement Name System
Display and Incorporate Transfer of Care Summary LTPAC and PCP/PCMH EHR Systems
Display and Incorporate Consultation Request ED EHR System
Clinical Summary
Display and Incorporate Shared Care Encounter LTPAC and PCP/PCMH EHR Systems
Summary
11 Table 7: System Requirements of Scenario 1 User Stories 1 and 2
TBD 30
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 10.3 Sequence Diagrams of Scenario 1 User Stories 1 and 2
2 The following sequence diagrams describe the messages and order of messages.
3 User Story 1: The Exchange of Transfer of Care Summary for the Discharge of a Patient from Hospital
4 to Home Health Agency.
Hospital Inpatient EHR System HHA Information System PCP/PCMH EHR System
1. Prepares and sends
Transfer of Care
Summary to HHA and
PCP/PCMH 2B. Receives
2A. Receives Transfer of Transfer of
Care Summary and Care Summary
Initiates Assessment and Initiates
Assessment
5
6 Figure 4: Sequence Diagram of Scenario 1 User Story 1
7 User Story 2: The Exchange of Consultation Request Clinical Summary and Shared Care Encounter
8 Summary for the Referral of Patient from a Nursing Facility to ED and Return to Nursing Facility
NF Information System ED EHR Information System PCP/PCMH EHR System
2. Prepares and sends Consultation
Request Clinical Summary to ED
3. Receives Consultation
1. Intent to treat Request for Clinical
urgent symptoms Summary, evaluates
in ED patient, provides care
4B. Prepares and
4A. Sends NF System sends PCP/PCMH
Shared Encounter Summary Shared Encounter
Summary
9
10 Figure 5: Sequence Diagram of Scenario 1 User Story 2
11 *********PLEASE NOTE: The downloading of Patient Information to the PHR is included in Scenario 3:
12 Exchange of Clinical Summaries between Provider to Patient. ***********
13
14
TBD 31
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 11.0 Scenario 2: Exchange of the Home Health Plan of Care (HH-POC)
2 between Home Health Agency and Ordering PCP
3
4 11.1 User Story of Scenario 2
5 The LCC Baseline Use Case Scenario 2 describes the requirements for the Home Health Plan of Care (HH-
6 POC) as required by CMS. The Care Plan is a much broader concept that cuts across all trading partners
7 and will be explored in the LCC White Paper. The HH-POC will serve as a focused starting point to inform
8 ongoing work to build out the transactions that will facilitate Care Planning.
9 The User Story for the Home Health Plan of Care (HH-POC) describes the Initial, Interim and
10 Recertification transactions as set out in the scope section of this Use Case:
11 Scenario 2: Provider to Provider data exchanges for the Home Health Plan of Care (HH-POC)
12 including the following user stories:
13 a. HH-POC (Initial and Recertification): Home Health Agency (HHA) to Physician, Physician
14 to HHA;
15 b. Interim Changes to HH-POC: HHA to Physician, Physician to HHA.
16 As depicted in the following graphic, the HH-POC dataset overlaps with the datasets for the Transfer of
17 Care Summary, consultation request clinical summary and shared care encounter summary.
Plan of Care
1 – Test/Procedure
– Test/Procedure Request
2 Report
3 – Shared Care Encounter
– Consultation Request Clinical Summary
4 Summary
5 – Transfer of Care Summary
18
19 The data set for the HH-POC is based on the data elements required to support payment in the Home
20 Health Setting.
TBD 32
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 User Story: The Exchange of Information to Share the Initial, Interim Updates and Recertification
2 Home Health Plan of Care (HH-POC) for the purposes of update and signature
3 Initial HH-POC
4 The patient sees their primary care physician and is noted to have small neuropathic ulcer on a bunion
5 with cellulitis. Treatment is initiated. In this face to face encounter, the physician determines that the
6 patient lives at home, is homebound and requires home health services from a home health agency
7 (HHA).The physician communicates an initial order and instructions with sufficient justification, e.g.,
8 notes, to the HHA. After consulting with the patient and family, the HHA staff fills out an initial set of
9 information for the Home Health Plan of Care (HH-POC) in the HHA information system. The physician is
10 then consulted to approve additions or modifications to the initial order and instructions. The HHA staff
11 begins care and sends the approved HH-POC to the ordering physician to review and update with any
12 orders and to electronically sign. The signed HH-POC is sent back to the HHA system where the HHA
13 staff reviews the updated HH-POC to inform clinical care.
14 Interim Updates to HH-POC
15 The patient is receiving care at home from the Home Health Agency (HHA). An Initial Home Health Plan
16 of Care (HH-POC) has been constructed, signed and exchanged between HHA system and the ordering
17 Physician EHR system. With continued consultation with the patient and family, the HHA staff updates
18 the HH-POC with the physician and in the HHA system according to the current status of the patient and
19 executes the HH-POC. The updated HH-POC is sent to the ordering physician EHR system to review and
20 update with any interim orders. The ordering physician reviews and electronically signs the HH-POC. The
Comment [VNSoN4]: When electronic
21 signed HH-POC, containing interim orders, is sent back to the HHA system where the HHA staff reviews exchange becomes available, it makes sense to
22 the updated HH-POC to inform clinical care. support interim updates from the Physician EMR
23 also, which we need to address in the use case
either as part of the base scenario or as an
assumption.
24 Recertification of HH-POC
Comment [kc5]: Need to acknowledge that
25 At 60 days after the initiation of care, the patient is assessed for Recertification. An updated HH-POC is either HHA or PCP can initiate updates. However,
26 sent from the HHA to the ordering physician to review and update with any orders and electronically the end-point business case and work flow and
27 sign. The signed HH-POC is sent back to the HHA system where the HHA staff reviews the updated HH- timing is out of scope.
28 POC to inform clinical care. The HHA staff executes the HH-POC. Comment [kc6]: Add assumption language to
indicate that the physician system can initiate
updates to the HH-POC.
29 Assumptions for Scenario 2:
Comment [VNSoN7]: If this is our assumption,
30 Some activities and information exchanges involved in developing and starting an initial HH-POC are out then updates to the initial POC on line 12 above
should be removed
31 of scope for detailed activities. Specifically we assume that the HHA develops an initial HH-POC based on
Comment [kc8]: Focused on the transaction and
32 its patient assessment and physician verbal orders. It is further assumed that the HHA begins to deliver the business
33 care based on this initial POC during the period prior to the HHA receipt of the physician signed HH-POC.
Comment [VNSoN9]: In some cases, the
34 In the base flow, it is assumed that the physician receives, accepts and signs the initial HH-POC as sent physician will never sign the POC. There are 2
35 by the HHA. These negotiations and modifications are assumed out of scope for the base flow. However, alternate flows for the initial POC that we may
36 ultimately the physician returns a signed HH-POC (Step 3 below) to the HHA which incorporates it into address in this assumption section – that the
physician may make updates to the POC and how
37 its system (Step 4 below). we plan to handle the updates, and that the
physician may not sign the POC and has indicate the
38 11.1.1 Base Flow of Scenario 2 reason and how we plan to handle that reason.
Actually, these 2 alternate flows are true for initial,
39 User Story: The Exchange of Information to Share the Initial, Interim Updates and Recertification interim and recertification POCs.
40 Home Health Plan of Care (HH-POC) for the purposes of update and signature Comment [kc10]: Will follow-up with Marie
from VNSNY to ensure these changes make sense.
TBD 33
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Step Actor Event/Description Inputs Outputs
#
1 HHA Information System Initiates HH-POC in Patient Initial HH-POC
HHA System Assessment and
Physician Verbal
Orders
2 HHA Information System Sends HH-POC to Initial HH-POC Initial HH-POC
PCP/PCMH
3 PCP/PCMH EHR System Sends Signed Initial Initial HH-POC Signed Initial HH-
HH-POC to HHA POC
4 HHA Information System Receives Signed Signed Initial Stored in HHA
Initial HH-POC from HH-POC System
PCP/PMCH
5 HHA Information System Sends HH-POC Interim Updates Interim updates to
interim updates to HH-POC
PCP/ PCMH
6 PCP/PCMH EHR System Sends signed Interim updates Signed and
interim updates to to HH-POC Updated HH-POC
HH-POC to HHA
7 HHA Information System Receives signed Signed Interim Updated HH-POC
interim updates to updates to HH-
HH-POC from POC
PCP/PCMH
8 HHA Information System Sends Recertification Recertification
Recertification HH- Updates to HH- HH-POC
POC to PCP/PCMH POC
9 PCP/PCMH EHR System Sends Signed Recertification Signed
Recertification HH- HH-POC Recertification
POC to HHA HH-POC
10 HHA Information System Receives Signed Signed Stored in HHA
Recertification HH- Recertification System-End
POC from HH-POC
PCP/PCMH
1 Table 8: Base Flow of Scenario 2 User Story
2
TBD 34
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 11.1.2 Activity Diagrams for Scenario 2
2 The following are the Activity Diagrams to support the events in section 11.1.1.
3 User Story: The Exchange of Information to Share the Initial, Interim Updates and Recertification
4 Home Health Plan of Care (HH-POC) for the purposes of update and signature
5 HHA Information System PCP/PCMH EHR System
6
1. Initiates HH-POC in
7 HHA System
8
9
10 2. Sends HH-POC to 3. Sends signed Initial
PCP/PCMH HH-POC to HHA
11
12
13
4. Receives signed Initial
14 HH-POC from PCP/PCMH
15
16
17 6. Sends signed Interim
5. Sends HH-POC Interim
updates to HH-POC to
18 updates to PCP/PCMH
HHA
19
20
21
7. Receives signed Interim
HH-POC from PCP/PCMH
22
23
24
25 8. Sends Recertification
9. Sends signed
Recertification updates to
HH-POC to PCP/PCMH
HH-POC to HHA
26
27
28
10. Receives signed
29 Recertification HH-POC
from PCP/PCMH
30
31 Figure 7: Activity Diagram of Scenario 2 User Story
TBD 35
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 11.2 Functional Requirements Scenario 2
2 11.2.1 Information Exchange Requirements of Scenario 2
3
Dataset Initiating Information Receiving
Transaction Type System Interchange System
Requirement Name
1A POC HHA Sends Initial HH-POC Receives PCP/PCMH
Information EHR System
System
1B POC PCP/PCMH Sends Signed Initial HH-POC Receives HHA
EHR System Information
System
2A POC HHA Sends Interim Updates to Receives PCP/PCMH
Information HH-POC EHR System
System
2B POC PCP/PCMH Sends Signed Interim Receives HHA
EHR System Updates to HH-POC Information
System
3A POC HHA Sends Recertification HH-POC Receives PCP/PCMH
Information EHR System
System
3B POC PCP/PCMH Sends Signed Recertification Receives HHA
EHR System HH-POC Information
System
4 Table 9: Informational Exchange Requirements of Scenario 2 User Story
5 11.2.2 System Requirements of Scenario 2
6
System Requirement Name System
Display and Incorporate HH-POC LTPAC and PCP HER/PCMH System
7 Table 10: System Requirements of Scenario 2
8
TBD 36
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 11.3 Sequence Diagrams of Scenario 2
2 The following sequence diagrams describe the messages and order of messages.
3 User Story: The Exchange of Information to Share the Initial, Interim Updates and Recertification
4 Home Health Plan of Care (HH-POC) for the purposes of update and signature
HHA Information System PCP/PCMH EHR System
1. Initiates HH-POC in
HHA System
2. Sends HH-POC to PCP/PCMH
3. Sends signed Initial HH-POC
to HHA
4. Receives signed Initial
HH-POC from
PCP/PMCH
5. Sends HH-POC Interim updates
to PCP/PCMH
6. Sends signed Interim HH-POC
updates to HHA
7. Receives signed Interim
updates to HH-POC from
PCP/PMCH
8. Sends Recertification HH-POC
to PCP/PCMH
9. Sends signed Recertification
HH-POC to HHA
10. Receives signed
Recertification HH-POC
from PCP/PMCH
5
6 Figure 8: Sequence Diagram of Scenario 2 User Story
7 *********PLEASE NOTE: The downloading of Patient Information to the PHR is included in Scenario 3:
8 Exchange of Clinical Summaries and Home Health Plan of Care between Provider and Patient.
9 ***********
TBD 37
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 12.0 Scenario 3: The Copy of all Transitions of Care Transactions to the
2 Patient
3 Scenario 3 adds the patient transactions to Scenario 1 Transitions of Care. Text in red indicates
4 information and instructions that are specific to the patient transaction. The provider to provider
5 functional requirements are retained to provide context.
6 12.1 User Stories of Scenario 3
7 The User Stories illustrate a combination of events in the scenario flows which are described in further
8 detail in the tables that follow. The User Stories rely on the definition of broad datasets that were
9 outlined by the LCC WG. The datasets for Transitions of Care are nested as follows:
10 1. Test/ Procedure Report: Report from Outpatient testing, treatment, or procedure
11 2. Test/ Procedure Request: Referral to Outpatient testing, treatment, or procedure
12 3. Shared Care Encounter Summary: Office Visit, Consultation Summary, Return from the ED to the
13 referring facility
14 4. Consultation Request Clinical Summary: Referral to a consultant or the ED
15 5. Transfer of Care Summary: Permanent or long-term transfer to a different provider, care team or
16 Home Health Agency
17
18 Of these 5 datasets Scenario 1 focuses on types 3, 4 and 5. Type one and two are considered to be
19 included as a subset in types three, four and five. The datasets are considered to be overlapping making
20 dataset one a subset of dataset 2 and so on. The following diagram illustrates the overlapping nature of
21 the transitions of care datasets that are further described in this scenario.
TBD 38
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Type 3 Dataset:
• Office Visit to PHR
• Consultant to PCP
• ED to PCP, SNF, etc…
1 – Test/Procedure Report
2 – Test/Procedure Request
3 – Shared Care Encounter Summary
4 – Consultation Request Clinical Summary
Type 4 Dataset:
5 – Transfer of Care Summary Type 5 Dataset:
• PCP to Consultant • Hospital to SNF, PCP, HHA, etc…
• PCP, SNF, etc… to ED • Hospital, SNF, etc… to HHA
1
• PCP to new PCP
2 This diagram notes that there is more than one scenario for which the same dataset can be used. For the
3 patient interaction, it is the intent of this Baseline Use Case to focus on the following specific
4 transactions:
5 Scenario 3: Copy to the Patient of the Provider to Provider data exchanges for Transfers of Care
6 and Referral that support the following generic and [representative] interactions:
7 d. Acute Care Hospital to LTPAC site (Transfer of Care Summary);
8 e. LTPAC Site to Emergency Department/ Consultant (Consultation Request Clinical
9 Summary);
10 f. Emergency Department/ Consultant to LTPAC Site (Shared Care Encounter Summary).
11 However, it is intended that similar trading partners (e.g. Nursing Facilities or Inpatient Rehabilitation
12 Facilities receiving a patient from Acute Care) may also take advantage of the transactions that are
13 articulated in this Use Case and that future use cases will specifically consider the inclusion of new data
Comment [kc11]: Ensure concept of exemplar is
14 elements based on the needs of other specific trading partners (e.g. behavioral health, community- strongly conveyed. Datasets are not setting specific,
15 based organizations). but transition specific. Temporary/ Permanent,
elective or emergent. Assigned to Terry O.
TBD 39
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 User Story 1: The Exchange of Information to Support the Transfer of Patient Information from a
2 Provider to Patient - Discharge of a Patient from Hospital to Home Health Agency
31. As in Scenario 1 User Story 1, a patient is being discharged from the hospital to home care. The
4 attending physician prepares discharge orders, orders home care and with nursing staff prepares patient
5 instructions. Discharge instructions are given to the patient by his/her nurse or care manager on day of
6 discharge at or a short time before the physical discharge. The facility may elect to provide a simpler
7 more user-friendly form of discharge instructions for teaching purposes. The patient confirms that he or
8 she has received the instructions from the nurse (verbally, in writing, and/or electronically). The
9 instructions may be generic, patient specific, or disease specific depending on the facility’s practices and
10 the patient’s needs. The nurse or case manager may make a notation in the EHR that the instructions
11 and other materials comprising the discharge information document set were completed. Patient
12 signature that s/he has participated in design of (shared decision-making) or reviewed and agreed to
13 adhere to the discharge instructions triggers the physical discharge sequence of events and patient
14 transport out of the facility.
152.
163. The patient is advised that the hospital has sent a Transition of Care Summary and the discharge
17 instructions to the home health agency, , and to the patient’s PCP/PCMH. The patient is further advised
18 that he/she may view, download or send this summary to a PHR or other system. Further information on
19 the hospital admission will also be made available per original Transition of Care guides.
20
21 User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the
22 Referral from a Nursing Facility to ED and from ED to Nursing Facility
23 Setting 1: Nursing Facility (sends consultation request clinical summary to Emergency Department/
24 Consultant).
25 As in Scenario 1User Story 2, a patient is receiving care in a nursing facility (NF). Over a weekend
26 evening, the patient experiences unexpected respiratory problems. The nurse on duty checks with the
27 NF physician who instructs the NF to send the patient to the local hospital’s emergency department (ED)
28 for evaluation. The NF transmits a consultation request clinical summary for the patient to the ED.
29 Setting 2: Emergency Department (sends Shared Care Encounter Summary to Nursing Facility and
30 PCP/ PCMH).
314. Following evaluation and treatment, the ED sends the patient back to the nursing facility and sends a
32 shared care encounter summary documenting care to the NF and the patient’s PCP/PCMH. This may
33 include specific patient instructions as well as information on how to access the shared care encounter
34 summary.
355. The patient and designated representative are provided information by the ED and the NF on how to
36 view, download or send both the original consultation request clinical summary sent by the NF to the ED
37 and the returned shared care encounter summary from the ED.
38 12.1.1 Base Flow of Scenario 1
39 User Story 1: The Exchange of Information to Support the Transfer of Patient Information from a
40 Provider to Patient - Discharge of a Patient from Hospital to Home Health Agency
TBD 40
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Step # Actor Event/Description Inputs Outputs
1 Provider Creates Discharge Order and START Orders for
Order for Home Health Care Discharge and
(HHA) Home Health Care
2 Hospital Inpatient Prepares and sends Transfer of Discharge Order Transfer of Care
EHR System Care Summary to HHA, Summary and
PCP/PCMH and Patient PHR Discharge
Instructions
3A HHA Information Receives Transfer of Care Transfer of Care END
System Summary and Initiates Summary
Assessment
3B PCP/PCMH EHR Receives Transfer of Care Transfer of Care END
System Summary Summary
3C Patient PHR Receives Transfer of Care Transfer of Care END
Summary Summary
1 Table 11: Base Flow of Scenario 3 User Story 1
2 User Story 2: The Story 2: The Exchange of Clinical Summaries between Provider and Patients to
3 Support the Referral from a Nursing Facility to ED and Return from ED to Nursing Facility
Step # Actor Event/Description Inputs Outputs
1 NF Information Intent to treat urgent symptoms START Order for ED
System in ED Referral
2 NF Information Prepares and sends Consultation Order for ED Consultation
System Request Clinical Summary to ED Referral Request
and Patient PHR Clinical
Summary
3 ED EHR Information Receives Consultation Request Consultation Shared Care
System Clinical Summary; evaluates Request Clinical Encounter
patient, provides care and sends Summary Summary
patient and Shared Care
Encounter Summary back to NF,
PCP/ PCMH and Patient PHR
3A Patient PHR Receives Consultation Request Consultation END Comment [M12]: I think numbering this as “3A”
Clinical Summary Request Clinical is confusing since the summary is coming from step
#2.
Summary
4A NF Information Receives Shared Care Encounter Shared Care END
System Summary Encounter Summary
4B PCP/PCMH EHR Receives Shared Care Encounter Shared Care END
System Summary Encounter Summary
TBD 41
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
4C Patient PHR Receives Shared Care Encounter Shared Care END Comment [M13]: I would recommend moving
Summary Encounter Summary this row below the PCP (currently step #5)
1 Table 12: Base flow of Scenario 3 User Story 2 Comment [kc14]: Update Diagrams based on
simplified flow. With no admit.
2
3 12.1.2 Activity Diagrams for Scenario 3
4 The following are the Activity Diagrams to support the events in section 12.1.1.
5 User Story 1: The Exchange of Information to Support the Transfer of Patient Information from a
6 Provider to Patient - Discharge of a Patient from Hospital to Home Health Agency
Provider Hospital Inpatient EHR HHA Information System PCP/PCMH EHR System Patient PHR
System
2. Prepares and sends
1. Creates discharge 3A. Receives Transfer of
Transfer of Care 3B. Receives Transfer of 3C. Receives Transfer of
order and order for skilled Care Summary and
document to HHA, PCP/ Care Summary Care Summary
care (HHA) initiates assessment
PCMH and Patient PHR
7
8 Figure 9: Activity Diagram of Scenario 3 User Story 1
9 User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the
10 Referral from a Nursing Facility to ED and Return from ED to Nursing Facility
NF Information System ED EHR Information System PCP/PCMH EHR System Patient PHR
1. Intent to treat urgent
symptoms in ED
3. Receives Consultation
Request for Clinical
2. Prepares and sends
Summary, evaluates 3A. Receives
Consultation Request
patient, provides care, Consultation Request
Clinical Summary to ED
sends patient and report Clinical Summary
and Patient PHR
back to NF, PCP/PCMH
and Patient PHR
4A. Receives Shared 4B. Receives Shared 4C. Receives Shared
Encounter Summary Encounter Summary Encounter Summary
11
12 Figure 10: Activity Diagram of Scenario 1 User Story 2
TBD 42
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 12.2 Functional Requirements of Scenario 1
2 12.2.1.1 Information Exchange Requirements of Scenario 1 User Story 1
3
Dataset Initiating Action Information Action Receiving
Transaction Type System Interchange System
Requirement Name
1 Type 5 Hospital Sends Transfer of Care Receives HHA
Inpatient EHR Summary (discharge Information
System summary and System
instructions)
1A Type 5 Hospital Sends Transfer of Care Receives PCP/ PCMH
Inpatient EHR Summary (discharge EHR System
System summary and
instructions)
1B Type 5 Hospital Sends Transfer of Care Receives Patient PHR
Inpatient EHR Summary (discharge
System summary and
instructions)
4 Table 13: Information Exchange Requirements of Scenario 3 User Story 1
5
6 12.2.1.2 Information Exchange Requirements of Scenario 3 User Story 2
7
Dataset Initiating Action Information Action Receiving
Transaction Type System Interchange System
Requirement Name
2 Type 4 NF Sends Consultation Request Receives ED EHR System
Information Clinical Summary
System
2A Type 4 NF Sends Consultation Request Receives Patient PHR
Information Clinical Summary
System
3A Type 3 ED EHR Sends Shared Care Receives NF Information
System Encounter Summary System
3B Type 3 ED EHR Sends Shared Care Received PCP/PCMH EHR
System Encounter Summary System Comment [M15]: Table 7 (for User Story 1)
shows receipt of the summary by both the HHA
3C Type 3 ED EHR Sends Shared Care Received Patient PHR
system and PCP system. Should we add this row for
System Encounter Summary the PCP system in order to be consistent?
8 Table 14: Information Exchange Requirements of Scenario 1 User Story 2
9
10
11
TBD 43
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 12.2.2 System Requirements of Scenario 3 User Stories 1 and 2
2
System Requirement Name System
Display and Incorporate Transfer of Care Summary LTPAC and PCP/PCMH EHR Systems Comment [M16]: Recommend including
Scenario 1 content to be consistent with other
Display and Incorporate Transfer of Care Summary Patient PHR tables.
Display and Incorporate Consultation Request ED EHR System
Clinical Summary
Display and Incorporate Consultation Request Patient PHR
Clinical Summary
Display and Incorporate Shared Care Encounter LTPAC and PCP/PCMH EHR Systems
Summary
Display and Incorporate Shared Care Encounter Patient PHR
Summary
3 Table 15: System Requirements of Scenario 1 User Stories 1 and 2
4 12.3 Sequence Diagrams of Scenario 3 User Stories 1 and 2
5 The following sequence diagrams describe the messages and order of messages.
6 User Story 1: The Exchange of Information to Support the Transfer of Patient Information from a
7 Provider to Patient - Discharge of a Patient from Hospital to Home Health Agency
Hospital Inpatient EHR System HHA Information System PCP/PCMH EHR System Patient PHR
1. Prepares and sends
Transfer of Care
Summary to HHA and
PCP/PCMH, and Patient 2A. Receives
PHR Transfer of 2B. Receives 2C. Receives
Care Summary Transfer of Transfer of
and initiates Care Summary Care Summary
Assessment
8
9 Figure 11: Sequence Diagram of Scenario 3 User Story 1
10
11
12
13
TBD 44
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 User Story 2: The Exchange of Clinical Summaries between Provider and Patients to Support the
2 Referral from a Nursing Facility to ED and from ED to Nursing Facility
NF Information System ED EHR Information System PCP/PCMH EHR System Patient PHR
2. Prepares and sends Consultation
Request Clinical Summary to
ED and Patient PHR
1. Intent to treat 3. Receives Consultation
urgent symptoms Request for Clinical
in ED Summary, evaluates
patient, provides care
4B. Sends PCP/PCMH 4C. Sends Patient PHR
4A. Sends NF System
Shared Care Shared Care
Shared Encounter Summary
Encounter Summary Encounter Summary
3
4 Figure 12: Sequence Diagram of Scenario 3 User Story 2
5 13.0 Scenario 4: Copy of Exchange of the Home Health Plan of Care (HH-
6 POC) between Home Health Agency and Ordering PCP to Patient
7
8 Scenario 4 adds the patient transactions to Scenario 2 Home Health Plan of Care. Red text indicates
9 information and instructions that are specific to the patient transaction. The provider to provider
10 functional requirements are retained to provide context.
11
12 13.1 User Stories of Scenario 4
13 The LCC Baseline Use Case Scenario 4 describes the requirements for the Home Health Plan of Care (HH-
14 POC). The Care Plan is a much broader concept that will cut across all trading partners and this is being
15 explored in the LCC White Paper. The HH-POC will serve as a focused starting point to inform ongoing
16 work to build out the transactions that will facilitate Care Planning.
17 The User Stories for the Home Health Plan of Care (HH-POC) describe the following transactions as set
18 out in the scope section of this Use Case:
19 Copy to the patient of provider-to-provider data exchanges for the Home Health Plan of Care
20 (HH-POC) including the following user stories:
21 a. HH-POC (Initial and Recertification): Home Health Agency (HHA) to Physician, Physician
22 to HHA;
23 b. Interim Changes to HH-POC: HHA to Physician, Physician to HHA.
24 As depicted in the following graphic, the HH-POC dataset overlaps with the Transfer of Care Summary
25 and consultation request and summary transaction datasets.
TBD 45
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Plan of Care
1 – Test/Procedure
– Test/Procedure Request
2 Report
3 – Shared Care Encounter
– Consultation Request Clinical Summary
4 Summary
5 – Transfer of Care Summary
1
2 The data set for the HH-POC is based on the data elements required to support payment in the Home
3 Health Setting.
4 User Story: The Exchange of Information to Share the Initial, Interim Updates and Recertification
5 Home Health Plan of Care (HH-POC) for the purposes of update and signature
6 Setting: Patient Home (Initial Order into Home Health care):
7 Initial HH-POC
8 The patient sees their primary care physician and is noted to have small neuropathic ulcer on a bunion
9 with cellulitis. Treatment is initiated. In this face to face encounter, the physician determines that the
10 patient lives at home, is homebound and requires home health services from a home health agency
11 (HHA).The physician communicates an initial order and instructions with sufficient justification, e.g.,
12 notes, to the HHA. After consulting with the patient and family, the HHA staff fills out an initial set of
13 information for the Home Health Plan of Care (HH-POC) in the HHA information system. The physician is
14 then consulted to approve additions or modifications to the initial order and instructions. The HHA staff
15 begins care and sends the approved HH-POC to the ordering physician to review and update with any
16 orders and to electronically sign. The signed HH-POC is sent back to the HHA system where the HHA
17 staff reviews the updated HH-POC to inform clinical care. A copy of the HH-POC is also made available to
18 the patient for viewing, downloading or sent to the patient.
19 Interim Updates to HH-POC
20 The patient is receiving care at home from the Home Health Agency (HHA). An Initial Home Health Plan
21 of Care (HH-POC) has been constructed, signed and exchanged between HHA system and the ordering
22 Physician EHR system. With continued consultation with the patient and family, the HHA staff updates
TBD 46
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 the HH-POC in the HHA system according to the current status of the patient. The updated HH-POC is
2 sent to the ordering physician EHR system to review and update with any interim orders. The ordering
3 physician electronically signs the HHPOC. The signed HH-POC, containing interim orders, is sent back to
4 the HHA system where the HHA staff reviews the updated HH-POC to inform clinical care. A copy of the
5 Interim HH-POC is made available for viewing or downloading by the patient or sent directly to the
6 patient PHR. The HHA staff executes the HH-POC.
7 Recertification of HH-POC
8 At 60 days after the initiation of care, the patient is assessed for Recertification. An updated HH-POC is
9 sent from the HHA to the ordering physician to review and update with any orders and electronically
10 sign. The signed HH-POC is sent back to the HHA system where the HHA staff reviews the updated HH-
11 POC to inform clinical care. A copy of the Interim HH-POC is made available for viewing or downloading
12 by the patient or sent directly to the patient PHR. The HHA staff executes the HH-POC.
13 Refer to Section 11 for assumptions related to HH-POC transactions in the Baseline Use Case. Comment [kc17]: Provide link to assumptions
text.
14 13.1.1 Base Flow of Scenario 4
15 User Story: The Exchange of Information to Share the Initial, Interim Updates and Recertification
16 Home Health Plan of Care (HH-POC) for the purposes of update and signature
Step Actor Event/Description Inputs Outputs
#
1 HHA Information Initiates HH-POC in HHA Patient Initial HH-POC
System System Assessment
2 HHA Information Sends Plan of Care to Initial Home Initial HH-POC
System PCP/PCMH Health input into
HH-POC
3 PCP/PCMH EHR Sends Signed Initial Plan Initial HH-POC Initial HH-POC
System of Care to HHA
4 HHA Information Receives Initial HH-POC Initial or HH-POC Stored in HHA System
System from PCP/PMCH
4A Patient PHR Receives Initial HH-POC Initial HH-POC Stored in PHR
from PCP/PMCH
5 HHA Information Sends HH-POC interim Interim Updates Interim updates to HH-POC
System updates to PCP/ PCMH
6 PCP/PCMH EHR Sends signed interim Interim updates to Updated HH-POC
System updates to Plan of Care HH-POC
to HHA
7 HHA Information Receives interim Interim updates to Updated HH-POC
System updates to HH-POC POC
7A Patient PHR Receives interim Interim updates to Stored in PHR
changes to POC POC
8 HHA Information Sends Recertification Recertification Recertification HH-POC
System HH-POC to PCP/PCMH Updates into HH-
POC
9 PCP/PCMH EHR Sends Signed Recertification Recertification HH-POC
TBD 47
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
Step Actor Event/Description Inputs Outputs
#
System Recertification Plan of HH-POC
Care to HHA
10 HHA Information Receives Recertification Recertification Stored in HHA System - End
System HH-POC from HH-POC
PCP/PMCH
10A Patient PHR Receives Recertification Recertification Stored in PHR
HH-POC from HH-POC
PCP/PMCH
1 Table 16: Base Flow of Scenario 4 User Story
2
TBD 48
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1
2 13.1.2 Activity Diagrams for Scenario 4
3 The following are the Activity Diagrams to support the events in section 13.1.1.
4 User Story: The Exchange of Information to Share the Initial, Interim Updates and Recertification
5 Home Health Plan of Care (HH-POC) for the purposes of update and signature
6 HHA Information System PCP/PCMH EHR System Patient PHR
7
1. Initiates HH-POC in
HHA System
8
9
10
2. Sends HH-POC to 3. Sends signed Initial
PCP/PCMH HH-POC to HHA
11
12
13 4. Receives signed Initial 4A. Receives Initial HH-
HH-POC from PCP/PCMH POC from PCP/PCMH
14
15
16 5. Sends HH-POC Interim
6. Sends signed Interim
updates to HH-POC to
updates to PCP/PCMH
HHA
17
18
19 7A. Receives Interim
7. Receives signed Interim
changes to POC from
HH-POC from PCP/PCMH
PCP/PCMH
20
21
22 9. Sends signed
8. Sends Recertification
Recertification updates to
HH-POC to PCP/PCMH
23 HH-POC to HHA
24
25 10. Receives 10A. Receives
Recertification HH-POC Recertification HH-POC
from PCP/PCMH from PCP/PCMH
26
27
28
29
30
31 Figure 13: Activity Diagram of Scenario 4 User Story
TBD 49
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 13.2 Functional Requirements Scenario 4
2 13.2.1 Information Exchange Requirements of Scenario 4
3
Dataset Initiating Information Receiving
Transaction Type System Interchange System
Requirement Name
1A HH-POC HHA Provider EHR
Information Sends Initial HH-POC Receives System
System (PCMH/PCP)
1B HH-POC Provider EHR Sends Signed Initial HH- Receives HHA
System POC Information
(PCMH/PCP) System
1C HH-POC Provider EHR Sends Signed Initial HH- Receives Patient PHR
System POC System
(PCMH/PCP)
2A HH-POC HHA Sends Interim Updates to Receives Provider EHR
Information HH-POC System
System (PCMH/PCP)
2B HH-POC Provider EHR Sends Signed Interim Receives HHA
System Updates to HH-POC Information
(PCMH/PCP) System
2C HH-POC Provider EHR Sends Signed Interim Receives Patient PHR
System Updates to HH-POC System
(PCMH/PCP)
3A HH-POC HHA Provider EHR
Recertification HH-
Information Sends Receives System
POC
System (PCMH/PCP)
3B HH-POC Provider EHR Sends Signed Receives HHA
System Recertification HH- Information
(PCMH/PCP) POC System
3C HH-POC Provider EHR Sends Signed Receives Patient PHR
System Recertification HH- System
(PCMH/PCP) POC
4 Table 17: Informational Exchange Requirements of Scenario 4 User Story
5 13.2.2 System Requirements of Scenario 4
6
System Requirement Name System
Display and Incorporate HH-POC LTPAC, PCP EHR System and PHR System
7 Table 13: System Requirements of Scenario 4
8 13.3 Sequence Diagrams of Scenario 4
9 The following sequence diagrams describe the messages and order of messages.
TBD 50
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 User Story 1: The Exchange of Information to Share the Initial, Interim Updates and Recertification
2 Home Health Plan of Care (HH-POC) for the purposes of update and signature
HHA Information System PCP/PCMH EHR System Patient PHR
1. Initiates HH-POC in
HHA System
2. Sends HH-POC to PCP/PCMH
3. Sends signed Initial HH-POC 4A. Sends initial HH-POC
to HHA to patient PHR
4. Receives signed Initial
HH-POC from
PCP/PMCH
5. Sends HH-POC Interim updates
to PCP/PCMH
6. Sends signed Interim HH-POC 7A. Sends Interim HH-POC
updates to HHA to patient PHR
7. Receives signed Interim
updates to HH-POC from
PCP/PMCH
8. Sends Recertification HH-POC
to PCP/PCMH
9. Sends signed Recertification 10A. Sends Recertification HH-POC
HH-POC to HHA to patient PHR
10. Receives signed
Recertification HH-POC
from PCP/PMCH
3
4 Figure 14: Sequence Diagram of Scenario 4 User Story
5 *********PLEASE NOTE: The downloading of Patient Information to the PHR is included in Scenario 3:
6 Exchange of Clinical Summaries and Home Health Plan of Care between Provider and Patient.
7 ***********
8
9
10
11
12
TBD 51
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 APPENDICES
2 Appendix A: Related Use Cases
3 AHIC Consultations and Transfers of Care
4 AHIC Consumer Empowerment; Consumer Access to Clinical Information
5 AHIC Common Data Transport
6 AHIC Clinical Notes Detail
7 AHIC Personalized Healthcare
8 NHIN Direct Primary care provider refers patient to consultant including summary care record
9 NHIN Direct Primary care provider refers patient to hospital including summary care record
10 NHIN Direct Consultant sends summary care information back to referring provider
11 NHIN Direct Hospital sends discharge information to referring provider
12 Appendix B: Previous Work Efforts Related to Clinical Information Exchange
13 Health Information Technology Standards Panel Specification IS03: The Consumer
14 Empowerment and Access to Clinical Information via Networks Interoperability Specification
15 defines specific standards needed to assist patients in making decisions regarding care and
16 healthy lifestyles (i.e., registration information, medication history, lab results, current and
17 previous health conditions, allergies, summaries of healthcare encounters and diagnoses). This
18 Interoperability Specification defines specific standards needed to enable the exchange of such
19 data between patients and their caregivers via networks.
20 Health Information Technology Standards Panel Specification IS09: The Consultations and
21 Transfers of Care Interoperability Specification describe the information flows, issues and
22 system capabilities that apply to a provider requesting and a patient receiving a consultations
23 from another provider.
24 HITSP Information Technology Standards Panel Specification C32: The Summary Documents
25 Using HL7 Continuity of Care Document (CCD) Component describes the document content
26 summarizing a consumer's medical status for the purpose of information exchange. The content
27 may include administrative (e.g., registration, demographics, insurance, etc.) and clinical
28 (problem list, medication list, allergies, test results, etc) information. This Component defines
29 content in order to promote interoperability between participating systems such as Personal
30 Health Record Systems (PHRs), Electronic Health Record Systems (EHRs), Practice Management
31 Applications and others.
32 Health Information Technology Standards Panel Specification C83: The CDA Content Modules
33 Component defines the content modules for document based HITSP constructs utilizing clinical
34 information. These Content modules are based on IHE PCC Technical Framework Volume II,
35 Release 4. That technical framework contains specifications for document sections that are
36 consistent with all implementation guides for clinical documents currently selected for HITSP
37 constructs. View the most current version as HTML
38 Health Information Technology Standards Panel Specification IS107: This Interoperability
39 Specification consolidates all information exchanges and standards that involve an EHR System
40 amongst the thirteen HITSP Interoperability Specifications in place as of the February 13, 2009
TBD 52
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 enactment of the American Recovery and Reinvestment Act (ARRA). This Interoperability
2 Specification is organized as a set of HITSP Capabilities, with each Capability specifying a
3 business service that an EHR system might address in one or more of the existing HITSP
4 Interoperability Specifications (e.g., the Communicate Hospital Prescriptions Capability supports
5 electronic prescribing for inpatient prescription orders)
6 Health Level 7: The CDA Release 2.0 provides an exchange model for clinical documents (such as
7 discharge summaries and progress notes) - and brings the healthcare industry closer to the
8 realization of an electronic medical record. By leveraging the use of XML, the HL7 Reference
9 Information Model (RIM) and coded vocabularies, the CDA makes documents both machine-
10 readable - so they are easily parsed and processed electronically - and human-readable - so they
11 can be easily retrieved and used by the people who need them. CDA documents can be
12 displayed using XML-aware Web browsers or wireless applications such as cell phones. While
13 Release 2.0 retains the simplicity of rendering and clear definition of clinical documents
14 formulated in Release 1.0 (2000), it provides state-of-the-art interoperability for machine-
15 readable coded semantics. The product of 5 years of improvements, CDA R2 body is based on
16 the HL7 Clinical Statement model, is fully RIM-compliant and capable of driving decision support
17 and other sophisticated applications, while retaining the simple rendering of legally-
18 authenticated narrative.
19 Appendix C: Privacy and Security Assumptions
20 Security attributes includes capabilities needed to establish trust between systems, provide
21 confidentiality while in-transit, ensure authenticity of the data, and ensure that only authorized
22 individuals have access to the data.
Feature Feature Applicability
Audit Logging X
Authentication (Person) X
Authentication (System) X
Data Integrity Checking X
Error Handling X
HIPAA De-Identification X
Holding Messages
Non-repudiation X
Pseudonymize and Re-Identify
Secure Transport X
Transmit Disambiguated Identities X
User Login X
23 Table 19: Common Transactions (not displayed as part of the sequence diagram)
24 Appendix D: Glossary
25 These items are included to clarify the intent of this use case. They should not be interpreted as
26 approved terms or definitions but considered as contextual descriptions. There are parallel activities
27 underway to develop specific terminology based on consensus throughout the industry.
TBD 53
Department of Health and Human Services (HHS) Office of the National Coordinator (ONC)
Use Case Development and Functional Requirements for Interoperability
Transition of Care and Plan of Care for LTPAC Use Case
1 Access Logs: An integrated view of who has accessed the consumer/patient’s health information for the
2 purposes of direct or indirect patient care.
3 Acute Care: Treatment for a short period of time in which the patient is treated for a brief episode of
4 illness. Acute Care is generally associated with care in a short term facility which is usually a non-
5 emergency department setting.
6 AHIC: American Health Information Community; a federal advisory body chartered in 2005, serving to
7 make recommendations to the Secretary of the U.S. Department of Health and Human Services in
8 regards to the development and adoption of health information technology.
9 Ancillary Entities: Organizations that perform auxiliary roles in delivering healthcare services. They may
10 include diagnostic and support services such as laboratories, imaging and radiology services, and
11 pharmacies that support the delivery of healthcare services. These services may be delivered through
12 hospitals or through free-standing entities.
13 Care Coordination: Functions that help ensure that the patient’s needs and preferences for health
14 services and information sharing across people, functions, and sites are met over time.
15 Care Coordinators: Individuals who support clinicians in the management of health and disease
16 conditions. These can include case managers and others.
17 Clinical Support Staff: Individuals who support the workflow of clinicians.
18 Clinicians: Healthcare providers with patient care responsibilities, including physicians, advanced
19 practice nurses, physician assistants, nurses, psychologists, pharmacists, and other licensed and
20 credentialed personnel involved in treating patients.
21 Consultation: Meeting of two or more clinicians to evaluate the nature and progress of disease in a
22 particular patient and to establish diagnosis, prognosis, and therapy.
23 Consumers: Members of the public that include patients as well as caregivers, patient advocates,
24 surrogates, family members, and other parties who may be acting for, or in support of, a patient
25 receiving or potentially receiving healthcare services.
26 Electronic Health Record (EHR): An electronic, cumulative record of information on an individual across
27 more than one healthcare setting that is collected, managed, and consulted by professionals involved in
28 the individual's health and care. This EHR description encompasses similar information maintained on
29 patients within a single care setting (a.k.a., Electronic Medical Record (EMR)).
30 Electronic Health Record (EHR) System Suppliers: Organizations which provide specific EHR solutions to
31 clinicians and patients such as software applications and software services. These suppliers may include
32 developers, providers, resellers, operators, and others who may provide these or similar capabilities.
33 Geographic Health Information Exchange/Regional Health Information Organizations: A multi-
34 stakeholder entity, which may be a free-standing organization (e.g., hospital, healthcare system,
35 partnership organization) that supports health information exchange and enables the movement of
36 health-related data within state, local, territorial, tribal, or jurisdictional participant groups. Activities
37 supporting health information exchanges may also be provided by entities that are separate from
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1 geographic health information exchanges/Regional Health Information Organizations including
2 integrated delivery networks, health record banks, and others.
3 Health Information Exchange (HIE): An electronic network for exchanging health and patient
4 information among healthcare delivery organizations, according to specific standards, protocols, and
5 other agreed criteria. These functional capabilities may be provided fully or partially by a variety of
6 organizations including free-standing or geographic health information exchanges (e.g., Regional Health
7 Information Organizations (RHIOs)), integrated care delivery networks, provider organizations, health
8 record banks, public health networks, specialty networks, and others supporting these capabilities. This
9 term may also be used to describe the specific organizations that provide these capabilities such as
10 RHIOs and Health Information Exchange Organizations.
11 Healthcare Payers: Insurers, including health plans, self-insured employer plans, and third party
12 administrators, providing healthcare benefits to enrolled members and reimbursing provider
13 organizations.
14 HITSP: The American National Standards Institute (ANSI) Healthcare Information Technology Standards
15 Panel; a body created in 2005 in an effort to promote interoperability and harmonization of healthcare
16 information technology through standards that would serve as a cooperative partnership between the
17 public and private sectors.
18 Laboratories: A laboratory (often abbreviated lab) is a setting where specimens are sent for testing and
19 analysis are resulted, and then results are communicated back to the requestor. The types of
20 laboratories may include clinical/medical, environmental, and veterinarian, and may be both private
21 and/or public.
22 ONC: Office of the National Coordinator for Health Information Technology; serves as the Secretary’s
23 principal advisor on the development, application, and use of health information technology in an effort
24 to improve the quality, safety, and efficiency of the nation's health through the development of an
25 interoperable harmonized health information infrastructure.
26 Patients: Members of the public who receive healthcare services. For hospice providers, the patient and
27 family are considered a single unit of care. Synonyms used by various healthcare fields include client,
28 resident, customer, patient and family unit, consumer, and healthcare consumer.
29 Personal Health Record: A health record that is initiated and maintained by an individual. An ideal PHR
30 would provide a complete and accurate summary of the health and medical history of an individual by
31 gathering data from many sources and making this information accessible online to anyone who has the
32 necessary electronic credentials to view the information.
33 Pharmacies: Entities that exist that are experts on drug therapy and are the primary health professionals
34 who optimize medication use to provide patients with positive health outcomes
35 Provider: An individual clinician in a care delivery setting who requests or accepts the transfer of the
36 clinical summary for the purposes of delivering care.
37 Provider Organizations: Organizations that are engaged in or support the delivery of healthcare. These
38 organizations could include hospitals, ambulatory clinics, long-term care facilities, community-based
39 healthcare organizations, employers/occupational health programs, school health programs, dental
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1 clinics, psychology clinics, care delivery organizations, pharmacies, home health agencies, hospice care
2 providers, and other healthcare facilities.
3 Registries: Organized systems for the collection, storage, retrieval, analysis, and dissemination of
4 information to support health needs. This also includes government agencies and professional
5 associations which define, develop, and support registries. These may include emergency contact
6 information/next of kin registries, patient registries, disease registries, etc.
7 Appendix E. References
8 American Health Information Community; AHIC;
9 www.hhs.gov/healthit/healthnetwork/background
10 The American National Standards Institute (ANSI) Healthcare Information Technology Standards
11 Panel; HITSP; www.HITSP.org
12 Health Level Seven; HL7; www.HL7.org
13 Meaningful Use Final Rule; Dept of Health and Human Services;
14 www.edocket.access.gpo.gov/2010/pdf/2010-17207.pdf
15 Nationwide Health Information Network; NHIN;
16 www.hhs.gov/healthit/healthnetwork/background
17 The ONC-SI-UC-Simplification Spreadsheet (Current Version)
18 http://wiki.siframework.org/Cross+Initiative+-+Use+Case+Simplification+SWG
19
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1 Appendix F. Sample CMS 485 Form
2
3
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1
2
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1
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