Integrating the Healthcare
Enterprise™ (IHE)
Patient Care Coordination
Functional Status Assessments
Use Case # 1
LTC to Acute Care
1
Use Case #1
Workflow Diagram
2
3
Nurse initiates
phone collaboration
withPCP
Nurse assesses
resident
4
Hosp admit nurse
reviews transmitted
EHR data
PCP reviews
patient status
Transfer
Patient?
9
8
7
Patient regains
strength,
progressing well
Attending reviews
patient status
10
Discharge planning
prepares patient
for discharge
Pt acuity &
staffing
levels rvw
PCP &
Attending
collaboration
Yes
6
Care providers
address pt’s medical
issues & POC
leading to discharge
Unit placement
5
Unit RN assesses
patient on
admission to unit
Patient transferred
to acute care hosp
11
Discharge
Patient to LTC?
Yes
Patient transferred
to long-term care
facility
Key:
Process
Decision
End of Process
Collaboration
Use Case #1
Dataflow Diagram
1
LTC assesses patient;
enters data in EHR for
functional assessment,
braden scale and
glucose level.
2
LTC nurse
discusses findings
from functional
assessment and labs
with patient’s PCP
10
Discharge planner
and nurse collaborate,
review functional
assessment
Document
Exchange
Server
3
4, 5, 6
PCP reviews patient
data via EHR;
assessment & labs
Hosp admit nurse
compares current
functional assessment
to LTC EHR data and
initiates POC
9
Attending reviews
progress notes,
functional assessments; writes orders
Document
Exchange
Server
8
7
Unit RN updates
daily assessments
in the EHR and
Plan of care
Unit RN updates
daily assessments
in the EHR and plan
of care
Patient transferred
to LTC facility
Key:
End of Process
Nurse
EHR
Physician
EHR
Ancillary
EHR
Use Case # 2
Assisted Living to ED to Acute Care to
Rehab
Use Case #2
Workflow
Diagram
3
4
1
2
Assisted living
resident falls and
Injures himself
Nurse assesses
patient
PCP & Nurse
collaborate on
patient injury
Patient transferred
by ambulance to
acute care facility
5
7
Patient evaluated
in emergency
department by RN
Patient evaluated
in emergency
department by doc
12
6
Attending, nurse,
surgeon, patient,
family collaborate
Yes
Surgery needed?
13
Patient has surgery
11
Surgical consult
15
Patient care
conference; patient
not able to function
independently
10
Unit RN assesses
patient on admit
to unit; POC initiated
9
8
Patient admitted
to orthopedic floor
ED doctor
reviews patient data
18
14
Patient begins
physical therapy
1 day post-op
Patient to radiology
for x-ray
Yes
Transfer
Patient?
Transfer
patient?
17
Discharge planning
prepares patient
for discharge
16
Surgeon
recommends
transfer to rehab
Patient transferred
by ambulance to
rehab facility
19
Rehab admit nurse
reviews transmitted
EHR data
Admit
Patient?
21
Care providers
address pt’s medical
issues & POC preparing for discharge
20
Patient regains
strength; requires
minimal assistance
Discharge
Patient?
Key:
22
23
Rehab doctor
recommends
transfer to assisted
living
Process
Decision
Yes
Patient transferred
To assisted living
facility
End of Process
Collaboration
Use Case #2
Dataflow Diagram
2
3
Assisted living staff
charts accident details, VS, pain, and
functional
assessment
Assisted living nurse
discusses findings
from assessment
and patient pain level
with patient’s PCP
15
14
Nurse and therapist
collaborate and
review patient’s
functional
assessment and POC
Physical therapist
evaluates patient,
establishes rehab
plan & sets goals
Document
Exchange
Server
Surgeon assesses
patient status;
reviews EHR data;
writes order for
transfer to rehab
Discharge planner
and nurse collaborate;
review functional
assessment
6, 7, 8
ED nurse assesses
patient; charts VS,
accident info, level
of pain (NRS) in EHR
ED doctor assesses
patient; orders x-ray;
writes admission
orders & surgical
consult
12
Physician, nurse, family
and patient collaborate
x-rays are shown;
discuss procedure pros
& cons; sign consent
17
16
5
Document
Exchange
Server
11
Surgeon reviews
EHR data on patient;
functional
assessment, level of
pain, labs, and x-rays
Key:
End of Process
Nurse
EHR
Physician
EHR
Ancillary
EHR
Document
Exchange
Server
Using functional
assessment and
pain scale
19
20
Rehab admit nurse
assesses patient
runctional status,
reviews EHR data;
assigns bed
Rehab RN updates
Functional
assessments in the
EHR including level of
pain
22
Patient data available
for review via EHR
9, 10
Hosp admit nurse
does functional
assessment, assesses
level of pain; reviews
EHR data; initiates
POC
Rehab doctor reviews
patient status and
EHR data; writes
order for discharge to
assisted living
21
Care providers
collaborate;
review functional
assessments and
update POC
Use Case # 3
Behavioral Health Hospital to Home
Health
Use Case #3
Workflow Diagram
1
Patient admitted to
adult unit in behavioral
health hospital
2
3
Hosp admit nurse
screens patient for
depression
Psychiatrist meets
with patient and
orders medication
9
Home health nurse
reviews patient data
via EHR
4
5
Social work evaluates patient’s social
& financial support
Unit RN assesses
patient daily for
depression
7
Yes
Discharge
Patient to home?
6
Patient care
conference; preparing
for discharge
Patient progressing
well & respond
-ing to therapy
10
Home health nurse
visits patient
11
Outpatient
psychiatrist reviews
patient data in EHR
Key:
Process
Decision
End of Process
Collaboration
Use Case #3
Dataflow Diagram
1
Psychiatrist reviews ED
data; assesses patient
and enters info in EHR;
admits patient to
adult unit of behavioral
health hospital
2
Behavioral health nurse
documents geriatric
depression scale and
initiates POC
9
3
4
Psychiatrist orders
anti-depressants &
mood stabilizers
via CPOE
Social worker
documents social and
financial assessment
information into EHR
7
Home health nurse
reviews geriatric
depression scores in
EHR and plans home
health visit
10
Home health nurse
visits patient; documents geriatric depression scores in
EHR
Document
Exchange
Server
5,6
Patient care team
meets; reviews geriatric depression scores
and prepare for
discharge
Unit RN documents
geriatric depression
scale score daily &
updates POC in EHR
11
Outpatient psychiatrist
reviews geriatric depression scores from
home health and
follows up w/patient
Patient data available
for review via HER
future visits
Key:
End of Process
Nurse
EHR
Physician
EHR
Ancillary
EHR
Back-up Slides
1
Use Case #1
Workflow Diagram
2
Nurse assesses
resident
3
Nurse initiates phone
Collaboration w/PCP
PCP reviews
patient status
4
5
Patient transferred
to acute care hosp
Hosp admit nurse
reviews transmitted
EHR data
Yes
Transfer
Patient?
10
9
8
Patient regains
strength,
progressing well
Attending reviews
patient status
Care providers
address patient’s
medical issues
Pt acuity &
staffing
levels rvw
7
6
Unit RN assesses
patient on
admission to unit
Unit placement
decision based on
current pt acuity,
& staffing levels
11
Discharge
Patient to LTC?
Yes
Patient transferred
to long-term care
facility
Key:
Process
Decision
End of Process
Use Case #1
Dataflow Diagram
1
LTC nurse
identifies change in
functional assessment,
braden scale and
glucose level.
2
LTC nurse
discusses findings
from assessment
and labs with
patient’s PCP
10
Attending reviews
progress notes
and assessments;
writes orders
RHIO
Document
Exchange
Server
3
PCP reviews EHR
Data on patient ;
assessment & labs
9
Unit RN updates
daily assessments
In the EHR
6
RHIO
Document
Exchange
Server
Hosp admit nurse
compares current
assessment to LTC
EHR data and
initiates POC
8
7
Unit RN updates
daily assessments
In the EHR
Unit RN updates
daily assessments
In the EHR
Patient transferred
to long-term care
facility
Key:
End of Process
Nurse
EHR
Physician
EHR
Use Case #1 Workflow Diagram
(Updated Audrey & Marcia)
Nurse assesses
resident
Identifies change in
functional assessment ,
braden scale and
glucose level.
PCP reviews status
RN initiates phone
collaboration with the
PCP. EHR reviewed,
decision to transfer to
acute care made.
Patient transferred to
acute care facility
RHIO
Document
Exchange
Server
Preparing patient for
discharge
Patient transferred to
long-term care facility
RHIO
Document
Exchange
Server
Progress note
Med reconciliation
Discharge summary
Hospital Admission
nurse reviews
transmitted EHR data.
Unit placement
decision based on
current patient acuity,
staffing levels.
Patient regains
strength; progressing
well
Unit RN
Updates
daily assessments
in the EHR
Unit RN assesses
Patient on admission
to unit
Unit RN compares
current assessment
to LTC EHR data and
initiates POC.
Care Providers
addresses
patient’s medical
issues
Unit RN updates
daily assessments
In the EHR.
Use Case #1
Combined Workflow/Dataflow Diagram
Nurse initiates
phone collaboration
with PCP
Nurse assesses
resident
PCP reviews
patient status
Patient transferred
to acute care
facility
RHIO
Document
Exchange
Server
Hospital admission
nurse reviews
transmitted EHR
data
Yes
Identifies change in
functional assessment,
braden scale and
glucose level.
Discharge
Patient to LTC?
Discusses findings
from assessment
and labs
Transfer
Patient?
Reviews EHR data
Attending reviews
patient status
Patient regains
strength,
progressing well
Attending reviews
progress notes
and assessments
Unit RN updates
daily assessments
In the EHR
Pt acuity &
staffing
levels rvw
Care providers
address patient’s
medical issues
Unit RN assesses
patient on
admission to unit
Unit placement
decision based on
current pt acuity,
& staffing levels
Unit RN updates
daily assessments
In the EHR
Unit RN updates
daily assessments
In the EHR
Nurse compares
Current assessment
to LTC EHR data and
initiates POC
Yes
RHIO
Document
Exchange
Server
Patient transferred
to long-term care
facility
Key:
Process
Decision
End of Process
Nurse
EHR
Physician
EHR