In collaboration with IHE

Care Theme: Transitions of Care
Use Case 14: Care Coordination Following ICU/Hospital Encounter
Primary Goal : Demonstrate the seamless transition of care between an intensive care unit, Med-Surg units, primary care physician
(PCP), and a consulting radiologist, despite care team members being in different departments, facilities, and communities.
Key Points: The demonstration illustrates how IHE profiles (including PIX, XDS, XDS-I, XCA, XCPD, XCA-I, ATNA, EDPN, MS, SWF, and others), patient care devices, and NHIN Direct protocol to demonstrate how a patient’s medical history, including device readings and images, are shared across multiple providers in multiple communities. The demonstration has a special focus on Patient Care
Devices (PCD), used by ICU staff to gather continuous bedside readings and manage alerts throughout the patient’s encounter.
This scenario follows a patient visit to the local Emergency Department with flu symptoms and shortness of breath, after which the patient is sent to the ICU for care. At the ICU, the care team monitors the patient through a sophisticated set of integrated medical devices that include a vital signs monitor, a physiologic monitor, a ventilator, infusion pump, and others. After being treated by both the intensive care and Med-Surg units, the patient is discharged, seen by a primary care physician and a consulting radiologist. Engagement in the recovery process is encouraged through use of both physician and patient portals to communicate important clinical and follow-up information.
Meaningful Use Relevance ( MU Objectives):
• Improving quality, safety, efficiency, and reducing health disparities
•
Improve care coordination
• Ensure adequate privacy and security protections for personal health information
Clinical Workflow :
46 year old patient from out of the area admitted through the ER with severe flu symptoms, disorientation, dehydration, and pneumonia.
The emergency room physician orders a study of the chest, which is performed by the hospital’s imaging department, and then transfers the patient to the ICU for further treatment and monitoring. During the night, the patient’s bedside monitor triggers an automated alarm, which requires immediate clinical attention and results in an adjustment of the patient’s medications. Once stabilized, the patient is moved to a med-surg unit for further care and monitoring, and is then discharged. The patient visits their PCP for follow-up care, who after reviewing the patient’s recent encounter history, refers the patient to a radiologist for a specialized review. Both the specialist and the patient follow the developing information made available via both a physician and a patient portal.

Care Theme: Transitions of Care
Use Case 14: Care Coordination Following ICU/Hospital Encounter
Clinical Workflow:
1- Imaging 2- ICU 4- Med/Surg Unit 4- Primary Care
5- Physician Portal 6- Radiologist 7- Patient Portal
1- Imaging: The patient is admitted through the ED and sent to Imaging for a CT study (PACS enabled department)
2- ICU monitoring and alert management: The patient is admitted to ICU where a host of patient care devices assist with monitoring and treatment of the patient.
3- Med/Surg Unit: Once stabilized the patient is sent to the medical unit for monitoring
– information is tracked and communicated using an EHR system and continually updated through various patient care devices.
4- Coordination with Ambulatory Care Communities:
• Follow-up: The patient visits their PCP for a follow-up visit. Duplicate tests are avoided through the availability and timely access to information from the hospital at the PCP’s office.
•
Radiologist referral: Radiologist consultation using an image viewing system and a Provider Portal
• Patient engagement: The patient follows their information through a Patient Portal

Care Theme: Transitions of Care
Use Case 8: ED Encounter Resulting in ICU/Inpatient Stay with Follow-up Care by PCP
IHE Profiles & Domains:
ATNA
Repository, Secure Application
CT Time Client, Time Server
CCDA Consumer, Source, Directory
IT Infrastructure (ITI)
Patient Care Coordination (PCC)
Patient Care Devices (PCD)
Radiology (RAD)
PIX, PIXv3
XCA
XCA-I
XCPD
XDR
XDS
EDPN
MS
DEC
SWF
XDS-I
Manager, Consumer, Identity Source
Initiating Gateway, Responding Gateway
Initiating Gateway, Responding Gateway
Initiating Gateway, Responding Gateway
Source, Recipient
Consumer, Source, Registry, Repository
Consumer, Creator
Consumer, Creator
Consumer, Reporter
Acquisition Modality, Order Filler, Order Placer,
Evidence Creator
Consumer, Source, Registry, Repository